Psych

Question 1

35 y/o man presents to A&E agitated and requesting medication. He has mild tremor, cool and clammy skin, and goosebumps (piloerection). Ambulance staff found him in the street with an empty bottle of cider. Temperature 36.8, BP 140/100, HR 100. What is the most likely diagnosis?

a. Alcohol intoxication
b. Alcohol withdrawal syndrome
c. Opiate intoxication
d. Opiate withdrawal syndrome
e. Tricyclic antidepressant intoxication

Answer 1

d. Opiate withdrawal syndrome

Question 2

20 y/o medical student attends A&E on the eve of an exam with difficulty breathing, palpitations, and chest tightness. She says she feels close to collapse, and feels like she is going to die. This has happened before and she was prescribed Propranolol but this is no longer effective, and she has routinely declined psychological interventions. Routine blood tests, ECG, and CXR are all normal. What is the most appropriate next step in her management?

a. Diazepam
b. Fluoxetine
c. Mirtazapine
d. Risperidone
e. Venlafaxine

Answer 2

b. Fluoxetine

Question 3

30 y/o white woman is on routine anti-psychotic medication for schizophrenia and has the following blood result:
Hb 140 (normal)
WCC (low)
Platelets 200 (normal)
Neutrophils 1.2 (low)
Lymphocytes 1.3 (normal)
Total cholesterol 5.3 (high)
Total cholesterol: HDL ratio 4.6 (high)
HbA1C 40 (normal)
What medication is she most likely taking?
a.	Aripiprazole
b.	Clozapine
c.	Haloperidol
d.	Quetiapine
e.	Risperidone

Answer 3

b. Clozapine

Question 4

29 y/o woman admitted to postnatal ward after emergency C-section. Midwife observes she has been acting bizarrely, hasn’t slept all night, and has been pacing up and down the ward. She appears distressed when seen and states her baby looks alien and “isn’t human”. What is the most likely diagnosis?

a. Baby blues
b. Bipolar affective disorder
c. Post-natal depression
d. Post-partum psychosis
e. Schizophrenia

Answer 4

d. Post-partum psychosis

Question 5

21 y/o woman admitted to psych ward for an acute episode. She has been prescribed Amisulpride for the past 3 weeks and is now worries she is pregnant because she has missed her period, however her pregnancy test is negative. Which blood test should be requested in addition to routine bloods?

a. Luteinising hormone
b. Progesterone
c. Prolactin
d. Thyroid stimulating hormone
e. Triglycerides

Answer 5

c. Prolactin

Question 6

15 y/o girl has 12 months of irritable mood, lack of pleasure, poor sleep, poor concentration, and low appetite. She is struggling to concentrate at school and is getting into trouble for low marks. What is the most appropriate first-line treatment?

a. Cognitive analytic therapy
b. Cognitive behavioural therapy
c. Family therapy
d. Fluoxetine
e. Sertraline

Answer 6

b. Cognitive behavioural therapy

Question 7

32 y/o woman in first trimester of pregnancy presents with low mood, difficulty sleeping, and poor concentration at work. A trial of CBT is ineffective. What is the most appropriate next step in management?

a. Interpersonal therapy
b. Psychodynamic psychotherapy
c. Sertraline
d. Venlafaxine
e. Short course of Zopiclone

Answer 7

c. Sertraline

Question 8

51 y/o man with Down syndrome has 6 months of poor self-care, increased aggression, and personality change. Recently he has been getting lost on the walk back from the shops to his house. Temperature 36.5, HR 85, BP 127/89, and urinanalysis is negative. What is the most likely diagnosis?

a. Alzheimer’s disease
b. Delirium
c. Depression
d. Hypothyroidism
e. Psychosis

Answer 8

a. Alzheimer’s disease

Question 9

19 y/o man with 1 day of fever, muscle stiffness, palpitations, and difficulty breathing. He has a history of psychotic depression for which he has been taking Fluoxetine for 6 weeks and Risperidone for 1 week. He is agitated with temperature of 39.8, HR 114, BP 172/89, and RR 30. Chest examination is otherwise clear, and neuro exam is normal except for globally increased tone. Which investigation would be most useful diagnostically?

a. CT head
b. ECG
c. EEG
d. Lumbar puncture
e. Serum creatine kinase

Answer 9

e. Serum creatine kinase

Question 10

23 y/o man admitted for 3rd person auditory hallucinations, irritability, and beliefs that his neighbours are watching him. This is the first time he has experienced these symptoms and they have lasted for 3 weeks. What is the most likely diagnosis?

a. Acute and transient psychotic disorder
b. Adjustment disorder
c. Paranoid personality disorder
d. Schizoaffective disorder
e. Schizophrenia

Answer 10

a. Acute and transient psychotic disorder

Question 11

15 y/o girl in A&E after fainting at school. BMI is 16, she has been restricting calorie intake for 1 year, she exercises every day and feels she is overweight. Which additional feature would be needed for a diagnosis of anorexia nervosa?

a. Bradycardia
b. Fear of gaining weight
c. Laxative abuse
d. Muscle weakness
e. Thinning of hair on head

Answer 11

b. Fear of gaining weight

Question 12

45 y/o man presents with worsening tremor for a few weeks. Has a history of schizophrenia in remission for which he is taking Haloperidol. There is bilateral tremor and cog-wheel rigidity in upper limbs. What is the most appropriate treatment for his symptoms?

a. Co-beneldopa
b. Entacapone
c. Pramipexole
d. Procyclidine hydrochloride
e. Selegiline hydrochloride

Answer 12

d. Procyclidine hydrochloride

Question 13

26 y/o woman with schizophrenia admitted to hospital after intentional paracetamol overdose. On day of discharge she breaks her bedside television because she heard the voice of her deceased grandmother telling her to do it. She wants to go home immediately and refuses to stay in hospital; the medical registrar decides detain her for further assessment. Which section of the Mental Health Act should be used here?

a. Section 2
b. Section 4
c. Section 5(2)
d. Section 5(4)
e. Section 136

Answer 13

c. Section 5(2)

Question 14

84 y/o man presents with gradual deterioration in memory for 3 years. He forgets details of conversations and to attend doctor’s appointments, though he can still manage his finances and cook and clean for himself. He regularly goes to the local shops and never gets lost. Which part of the brain is likely to be affected?

a. Cerebellum
b. Frontal lobe
c. Occipital lobe
d. Parietal lobe
e. Temporal lobe

Answer 14

e. Temporal lobe

Question 15

A 25 y/o man has tried Olanzapine and Haloperidol but continues to experience symptoms of schizophrenia. What is the most appropriate next step in his management?

a. Aripirazole
b. Clonazepam
c. Clozapine
d. Lithium
e. Quetiapine

Answer 15

c. Clozapine

Question 16

25 y/o woman has recurrent episodes of sudden onset sweating, dry mouth, “butterflies” in her stomach, difficulty breathing, and fear of impending death. These symptoms have been occurring twice weekly for the past 2 years. What is the most likely diagnosis?

a. Dissociative disorder
b. Generalised anxiety disorder
c. Hypochondriasis
d. Panic disorder
e. Somatisation disorder

Answer 16

d. Panic disorder

Question 17

19 y/o woman with OCD is prescribed Sertraline at the maximum dose but it doesn’t control her symptoms. She has been unable to attend university for 4 months, and CBT has not helped in the past. What is the most appropriate next step in her management?

a. Add another antidepressant
b. Change to an antidepressant of another class
c. Refer for additional and more intensive CBT
d. Refer for deep brain stimulation
e. Refer for ECT

Answer 17

b. Change to an antidepressant of another class

Question 18

53 y/o man with 2 years of low mood, poor concentration, and poor sleep that is now affecting job and family life, and he has become socially reclusive. He had an MI 2 years prior and has T2DM. He is referred for CBT but wants to start medication. Which is the most appropriate first medication?

a. Citalopram
b. Fluoxetine
c. Mirtazapine
d. Sertraline
e. Venlafaxine

Answer 18

d. Sertraline

Question 19

28 y/o man is given regular medication for BPAD and has also been taking Naproxen for a sports injury. He presents to A&E with ataxia, confusion, and tremor. Which medication has most likely caused his symptoms?

a. Carbamazepine
b. Lithium
c. Olanzapine
d. Sertraline
e. Sodium valproate

Answer 19

b. Lithium

Question 20

18 y/o man admitted under MHA to inpatient mental health unit for anorexia nervosa. He is commenced on nasogastric feeds and begins to show signs of confusion, weakness, and dyspnoea. Which electrolyte abnormality is most likely to be seen?

a. Hypercalcaemia
b. Hyperkalaemia
c. Hypomagnesaemia
d. Hyponatraemia
e. Hypophosphataemia

Answer 20

e. Hypophosphataemia

Question 21

25 y/o man attends A&E with headache. He is speaking rapidly and smiling as he talks. He scratches his skin constantly and claims to feel insects crawling up him. His temperature is 36.5, HR 130, and BP 154/84. What is the most likely diagnosis?

a. Alcohol withdrawal
b. Benzodiazepine withdrawal
c. Cannabis intoxication
d. Cocaine intoxication
e. Heroin withdrawal

Answer 21

d. Cocaine intoxication

Question 22

40 y/o Eritean veteran has an established diagnosis of PTSD, and describes feelings of anxiety in public spaces and waking up from nightmares in a state of panic. Maximum dose Sertraline and CBT are not helpful, which other treatment should be considered?

a. Debriefing
b. ECT
c. EMDR
d. Motivational interviewing
e. Psychodynamic psychotherapy

Answer 22

c. EMDR

Question 23

45 y/o man is taken to A&E by police who are concerned for his health after being in custody for 20 hours. He is known to consume alcohol to excess, and appears dishevelled, agitated, and is tremulous. Blood tests are unremarkable except for moderately deranged LFTs. What is the most likely diagnosis?

a. Alcohol withdrawal syndrome
b. Alcohol induced hepatitis
c. Hepatic encephalopathy
d. Opioid withdrawal syndrome
e. Wernicke’s encephalopathy

Answer 23

a. Alcohol withdrawal syndrome

Question 24

35 y/o man brought to A&E by police who found him roaming the streets naked, propositioning women for sex. Which MHA section has been used by police to detain him?

a. Section 4
b. Section 5(2)
c. Section 5(4)
d. Section 135
e. Section 136

Answer 24

e. Section 136

Question 25

58 y/o man attends addiction services for initial alcohol dependence assessment. He regularly attends A&E following overdose attempts. He requests detoxification. He lives alone with few social contacts and has poorly controlled asthma. What is the most appropriate next step in management?

a. CBT
b. Community detoxification
c. Disulfiram
d. Inpatient detoxification
e. Motivational interviewing

Answer 25

b. Community detoxification

Question 26

30 y/o man attends A&E with palpitations, dizziness, and chest pain – he is worried that he has had a heart attack. The chest pain is sharp and variable in location, and he gives a history of 6 months of low mood following being laid off from work. He has attended multiple local hospitals for several years and has reported a variety of different symptoms including headaches over the right ear, difficulty swallowing, and griping stomach pains, but says “the doctor’s haven’t been able to find out what’s wrong with me”. His ECG is normal. What is the most likely diagnosis?

a. Borderline personality disorder
b. Factitious disorder
c. Generalised anxiety disorder
d. Panic disorder
e. Somatisation disorder

Answer 26

e. Somatisation disorder

Question 27

A 35 y/o man with Fragile X syndrome lives alone, does voluntary work, and travels independently to familiar places, though he needs help planning travel to new areas. He attended a special needs school and has a carer supporting him by helping him to pay his bills. What is his most likely IQ?

a. 20
b. 40
c. 65
d. 80
e. 110

Answer 27

c. 65

Question 28

45 y/o man believes he is dead and does not exist. He says he feels miserable most of the time, and that his wife left him for another man 5 months ago. He has increased his alcohol intake and now has 3 pints of lager every day, and occasionally smokes cannabis. He has lost 7kg in weight over 3 months. What is the most likely diagnosis?

a. Alcohol induced psychosis
b. Delusional disorder
c. Depressive episode with psychotic symptoms
d. Psychosis secondary to illicit drug use
e. Schizophrenia

Answer 28

c. Depressive episode with psychotic symptoms

Question 29

28 y/o woman with history of depressive disorder is referred to community mental health team with a 3 day history of increased energy and restlessness; she has been working till 02:00 and writing new articles (she is the creative director of a magazine). She recognises that this is unusual for her, describes her mood as 10/10, and says she feels creative and full of ideas. What is the most likely diagnosis?

a. Agitated depression
b. Hypomania
c. Manic episode
d. Schizoaffective disorder
e. Schizophrenia

Answer 29

b. Hypomania

Question 30

25 y/o woman is brought to A&E after a fight in public where she fractured her hand. She is agitated and blames the other person for the altercation as they cut the queue. She has an extensive history of shoplifting in her teenage years. What is the most likely diagnosis?

a. Antisocial personality disorder
b. Anxious/ avoidant personality disorder
c. Histrionic personality disorder
d. Paranoid personality disorder
e. Schizoid personality disorder

Answer 30

a. Antisocial personality disorder

Question 31

48 y/o man has hypertension, anxiety, gout, and back pain. His routine ECG shows a QT interval of 460ms (380-440 normal range). Which is the most likely causative medication?

a. Allopurinol
b. Amitriptyline
c. Co-codamol
d. Diazepam
e. Ramipril

Answer 31

b. Amitriptyline

Question 32

4 y/o boy seen in GP with his mother because of concerns at school that he does not make friends easily, his speech is limited, and he is often seen on his own lining up Lego bricks by colour. What is the most likely diagnosis?

a. ADHD
b. Autism
c. Global developmental delay
d. Hearing impairment
e. Separation anxiety

Answer 32

b. Autism

Question 33

37 y/o woman attends GP for anxiety accompanied by her friend. She has been married for 20 years and tearfully tells the GP she cannot cope when he has to work abroad for a couple of months. She is worried about being left alone to fend for herself and that she can’t make everyday decisions without his help. What is the most likely diagnosis?

a. Adjustment disorder
b. Anxious/ avoidant personality disorder
c. Dependent personality disorder
d. Depressive disorder
e. Generalised anxiety disorder

Answer 33

c. Dependent personality disorder

Question 34

A 29 y/o woman in GP is complaining of palpitations, sweating, dry mouth, and paraesthesia each time she leaves the house. She has a PMHx of asthma. Which is the most appropriate drug class to use?

a. Atypical anti-psychotic
b. Benzodiazepine
c. Beta blocker
d. Sedating antihistamine
e. SSRI

Answer 34

e. SSRI

Question 35

38 y/o woman in GP has 8 months of amenorrhea on a background of T2DM and BPAD. Her pregnancy test is negative. Investigations:
Luteal LH 2.0 (normal)
Luteal FSH 2.0 (normal)
TSH 2.3 (normal)
Testosterone 1.0 (normal)
SHBG 80.0 (normal)
Prolactin 821 (high)
Which medication is most likely to have caused this?
a.	Diazepam
b.	Metformin
c.	Risperidone
d.	Sertraline
e.	Zopiclone

Answer 35

c. Risperidone

Question 36

70 y/o woman known to community mental health team sees her GP with new onset tremor, painful muscle contractions, dry mouth, and weight gain. Which medication is likely to be causing her symptoms?

a. Amitriptyline
b. Levodopa
c. Olanzapine
d. Paroxetine
e. Propranolol

Answer 36

c. Olanzapine

Question 37

28 y/o woman attends GP for 6 week post-natal check following emergency C-section. She is feeling tired, low in energy, has poor appetite, and is having some frightening thoughts or about hurting her baby. Which is the most likely diagnosis?

a. Adjustment disorder
b. Baby blues
c. PTSD
d. Post-natal depression
e. Puerperal psychosis

Answer 37

d. Post-natal depression

Question 38

73 y/o man in GP is distressed after his husband died 6 weeks ago. He has reduced appetite, trouble sleeping, and poor concentration. He questions whether life is worth living but has no active suicidal ideation. He still enjoys spending time with his grandchildren. What is the most likely diagnosis?

a. Generalised anxiety disorder
b. Moderate depressive disorder
c. Normal grief reaction
d. Persistent prolonged bereavement disorder
e. Prolonged grief disorder

Answer 38

c. Normal grief reaction

Question 39

24 y/o seen in GP for 6 months of low mood, poor concentration, and trouble sleeping. He denies suicidal ideation or self-harm. He denies drinking excessively, smoking at all, and using recreational drugs. He is a waiter and is struggling at work and has a PHQ-9 of 6 (mild severity). What is the most appropriate course of action?

a. Advise mindfulness classes
b. Refer for CBT
c. Start Citalopram
d. Start Fluoxetine
e. Write a fit note (medical certificate) for 4 weeks

Answer 39

b. Refer for CBT

Question 40

40 y/o man was punched in the face by his new partner and sustained a broken jaw 1 week ago. He now presents with panic attacks, nightmares, and suicidal thoughts. He ruminates about the incident and is unable to concentrate at work. What is the most likely diagnosis?

a. Acute stress reaction
b. Adjustment disorder
c. Depressive episode
d. Obsessive compulsive disorder
e. PTSD

Answer 40

a. Acute stress reaction

Question 41

8 y/o boy struggles to follow instructions for school work and can’t organise his time effectively to complete assigned tasks. He is fidgety and disrupts others in the class by interrupting of by being ‘on the go’ when expected to sit still. What would be the most appropriate medication?

Answer 41

Methylphenidate

Question 42

20 y/o woman presents to A&E with agitation, confusion, high temperature, sweating, muscle twitches, and diarrhoea. She was recently started on medication for depression. What is the most likely diagnosis?

Answer 42

Serotonin syndrome

Question 43

60 y/o man with schizophrenia is taking haloperidol and has developed uncontrolled repetitive movements of his jaw with grimacing and protrusion of his tongue. What phenomenon is this?

Answer 43

Tardive dyskinesia

Question 44

97 y/o woman has dementia and frequently tries to leave her nursing home at 03:00 in her nightgown to feed the swans. What legal framework may be considered in order to prevent her from leaving?

Answer 44

Deprivation of Liberty Safeguards

Question 45

55 y/o woman presents to A&E after taking an overdose of 6 paracetamol tablets following a relationship breakdown. She states her life is not worth living and she feels empty inside. She has numerous scars on her forearms. She has attended A&E 7 times this year with a similar presentation. What is the most likely diagnosis?

Answer 45

Borderline/ emotionally unstable personality disorder

Question 46

27 y/o woman reviewed by community mental health team for schizophrenia follow-up. She describes experiences where she thinks she isn’t real. What phenomenon is this?

Answer 46

Derealisation

Question 47

55 y/o man admitted to hospital 3 days ago for knee replacement. Now complaining of seeing ants crawling up his legs and appears confused and tremulous. What is the most likely diagnosis?

Answer 47

Delirium tremens

Question 48

78 y/o woman has had difficulty planning and with focus for past 6 months. She reports seeing people at her dining table that nobody else can see. What is the most likely diagnosis?

Answer 48

Lewy body dementia

Question 49

11 y/o boy excluded from school following destructive behaviour including arson and aggressive behaviour towards peers. He has repeatedly been cautioned by police for shoplifting. What is the most likely diagnosis?

Answer 49

Conduct disorder

Question 50

36 y/o man started on lithium for BPAD. He is scheduled to have regular monitoring of lithium levels, renal function, calcium, and glucose. Which other blood test should be monitored?

Answer 50

Thyroid function tests

Question 51

50 y/o man believes wife is cheating on him, gathering evidence by repeated obsessive examination of her underwear. What is the most likely psychiatric diagnosis?

Answer 51

Othello syndrome

Question 52

40 y/o woman attends A&E after her mother’s funeral with sudden onset blindness, but seems largely unconcerned about this new development. Physical examination and investigations are normal. What is the most likely disorder?

Answer 52

Conversion disorder

Question 53

87 y/o woman with indwelling catheter presents with sudden onset agitation and visual hallucinations. What is the most likely diagnosis?

Answer 53

Delirium (likely secondary to UTI)

Question 54

20 y/o man with schizophrenia tells his support worker that the TV news presenter talks about him. What psychotic phenomenon is he describing?

Answer 54

Delusion of reference

Question 55

56 y/o man brought to A&E by ambulance after he’s found collapsed in a park. His pupils are constricted and his RR is 6. Which mediation should be urgently administered?

Answer 55

Naloxone

Question 56

78 y/o woman has 2 weeks of progressive lethargy, nausea, and dizziness. She has depression and has recently increased her dose of Citalopram. What is the most likely biochemical abnormality?

Answer 56

Hyponatraemia

Question 57

22 y/o female with diagnosis of OCD presents to her GP for a repeat prescription of her medication. Which class of drug is first line for OCD?

Answer 57

Selective serotonin reuptake inhibitor

Question 58

40 y/o doctor has central chest pain but a normal ECG. 3 months ag he attended rapid access chest pain clinic but was discharged after normal exercise stress test. His only PMHx is chronic rhinitis. What is the most likely drug of abuse in this case?

Answer 58

Cocaine

Question 59

22 y/o woman has 6 months of restricted eating, amenorrhea, social anxiety, and low mood. She has fine hair on her face and her BMI is 16.8. Her observations are otherwise normal. What is the most appropriate first-line pharmacological intervention?

Answer 59

SSRI (Fluoxetine)

Question 60

16 y/o attends GP with difficulties at college: she fears sitting on public transport and feels scared to leave her house. She avoids the supermarket and now does her grocery shopping online. What is the most likely diagnosis?

Answer 60

Agoraphobia

Question 61

A 72 year old man has a 6 month history of low mood, poor sleep and poor appetite. His wife died 1 year ago. He complains of poor memory, forgetting to take his medication and forgetting appointment dates and neglecting to pay bills. He used to attend the community centre but no longer enjoys doing so. He feels hopeless about the future. He denies social ideation. Which is the most likely diagnosis?

a. Abnormal grief reaction
b. Adjustment disorder with depressed mood
c. Alzheimer’s disease
d. Severe depressive episode without psychotic features
e. Vascular dementia

Answer 61

d. Severe depressive episode without psychotic features

Question 62

A 28 year old man attends the clinic with his mother. He states that he has ‘had enough’ because his flatmates are Russian spies who are after him, follow him wherever he goes and he can hear them comment on his actions when they are not in the room with him. As a result of this, he has stopped going out and has limited his contact with his family and friends in recent months. Which of the features described is a negative symptom?

a. He believes that he is being followed
b. He believes that his flatmates are Russian spies
c. He has limited social contacts
d. He hears the voices of his flat mates
e. His flatmates’ voices comment on his actions

Answer 62

c. He has limited social contacts

Question 63

A 35 year old man has been feeling low in mood and has disturbed sleep. He has been taking fluoxetine 40 mg daily for 3 months, with no improvement. His treating doctor intends to commence him on citalopram 20 mg daily. Which is the most appropriate next step in regards to changing his medication?

a. Add citalopram to fluoxetine at the current dose, withdrawing fluoxetine only if patient’s syndrome improve
b. Cross taper, i.e. reduce the fluoxetine dose, simultaneously adding citalopram
c. Reduce fluoxetine dose to 20mg daily, discontinue it after 1 week and then immediately initiate citalopram
d. Reduce fluoxetine dose to 20mg daily and start citalopram after a 1 week washout period
e. Reduce fluoxetine dose to 20 mg daily and start citalopram after a 6 week washout period

Answer 63

d. Reduce fluoxetine dose to 20mg daily and start citalopram after a 1 week washout period

Question 64

An 18 year old woman has not eaten any solid food over the past week and has been limiting her liquid intake to 500 mL per day. She is preoccupied about being significantly overweight. Which blood test parameter is most likely to be raised in this scenario?

a. Cholesterol
b. Haemoglobin
c. Phosphate
d. Potassium
e. Triiodothyronine (T3)

Answer 64

a. Cholesterol

Question 65

A 46 year old woman attends a follow up appointment with the community mental health team. She has been taking venlafaxine 150mg daily for the past 3 months. She is feeling more energetic, requiring very little sleep, has been going out most evenings and is overspending. Which is the most appropriate next step in regards to her management?

a. Refer to the community mental health team
b. Start lithium
c. Start risperidone
d. Start sodium valproate
e. Stop venlafaxine

Answer 65

e. Stop venlafaxine

Question 66

A 30 year old woman is admitted to the mental health unit from the Emergency Department. She appears elated, apparently unconcerned that she has hardly slept in recent days and is talking about flying to the USA to assume the presidency. She was reported by her companion to have eaten soap. Her past psychiatric and medical history is unremarkable. Which is the most appropriate pharmacological intervention for this acute presentation?

a. Carbamazepine
b. Lithium
c. Olanzapine
d. Sertraline
e. Sodium valproate

Answer 66

c. Olanzapine

Question 67

The family of a 72 year old man have raised concerns about his memory, which has recently deteriorated. He has had a number of similar presentations over the past 3 years. Following each episode, his ability to communicate and care for himself has declined. His medical history includes diabetes, hypertension, hyperlipidaemia and transient ischaemic attacks. Which is the most likely diagnosis?

a. Alzheimer’s disease
b. Creutzfeld-Jakob disease
c. Frontotemporal dementia
d. Lewy body dementia
e. Vascular dementia

Answer 67

e. Vascular dementia

Question 68

A 20 year old woman attends the outpatient clinic following concerns by her GP about her eating habits. She significantly restricts her food intake and induces vomiting when she feels that she has overeaten. She speaks a lot about food and has started baking cakes, although she does not appear to eat them. She has not had a period for over 3 months. Her BMI is 18.5 kg/m2. She appears anxious when her diet is discussed. Which presenting feature most characteristically indicates a diagnosis of anorexia nervosa?

a. Amenorrhoea
b. Anxiety when discussing food
c. BMI of 18.5 kg/m2
d. Preoccupation with weight
e. Purging behaviour

Answer 68

d. Preoccupation with weight

Question 69

A 30 year old woman with type I diabetes mellitus has developed end-stage renal failure and requires dialysis. She believes that the hospital (where she is admitted) has conspired to intentionally give her diabetes. She is therefore refusing to have dialysis and is actively attempting to leave the hospital. She is able to retain the relevant information and communicate her decision to refuse dialysis, which she justifies based on her thoughts that dialysis will cause her further harm. Blood investigations: potassium 6.7 mmol/L (3.5 - 5.3), Urea 50 mmol/L (2.5 - 7.8), creatinine 1200 micromol/L (60 - 120). Which is the most appropriate next step in regards to her management?

a. Detain the patient under Section 5(2) of the Mental Health Act and provide emergency dialysis
b. Facilitate a Mental Health Act assessment
c. Facilitate an urgen best interests assessment
d. Facilitate dialysis under common law, using sedation if required
e. Facilitate discharge and continue discussions with the patient in the community

Answer 69

e. Facilitate discharge and continue discussions with the patient in the community

Question 70

A 27 year old woman with diabetes reports not sleeping for 1 week. She has recently ended her relationship with her partner of 5 years because she believes that he is a member of the CIA and has been uncharacteristically promiscuous. She states that she hears his voice even when she is not with him in the room. Which medication combination is most appropriate in this scenario?

a. Aripiprazole and sodium valproate
b. Clozapine and lithium
c. Olanzapine and carbamazepine
d. Quetiapine and lithium
e. Risperidone and lamotrigine

Answer 70

d. Quetiapine and lithium

Question 71

A 35 year old woman is referred to the mental health nurse based in her GP surgery, following multiple presentations over the last year with gynaecological symptoms. She has a regular menstrual cycle, but with the onset of menstruation, she becomes increasingly anxious that she has developed life-threatening internal bleeding. She is worried that she may have cancer of the uterus. Blood tests, including a full blood count, are within normal limits. Her blood pressure is normal. Which is the most likely diagnosis?

a. Conversion disorder
b. Factitious disorder
c. Hypochondrial disorder
d. Malingering
e. Somatisation disorder

Answer 71

c. Hypochondrial disorder

Question 72

A 19 year old woman writes to her new GP to profess her love for him. In the letter, she describes her belief that they are destined to marry, which she knew to be true after seeing his picture on the surgery’s website. Police have been contacted by her GP after she was seen to be following him home late at night. Which is the most likely diagnosis?

a. Acute stress reaction
b. De Clerambault syndrome (erotomanic delusions)
c. Emotionally unstable personality disorder
d. Normal adolescent development
e. Schizophrenia

Answer 72

b. De Clerambault syndrome (erotomanic delusions)

Question 73

A 50 year old man has been feeling low in mood and describes ‘not enjoying anything’ in recent weeks. He has difficulties concentrating at work, where his performance has been declining. He is unkempt and losing weight. He has seen his GP who initiated sertraline 100mg daily 1 month ago and referred him to the community mental health team. Which is the most appropriate next step in his management?

a. Add lithium
b. Add mirtazapine
c. Add olanzapine
d. Increase the dose of sertraline
e. Switch to dosulepin (a TCA)

Answer 73

d. Increase the dose of sertraline

Question 74

A 19 year old university student presents with a 3 week history of thinking that MI6 are out to get him. He believes that he is being monitored and checks his locks up to 20 times per day. He last used cannabis 3 years ago. At present he is euthymic. Which is the most likely diagnosis?

a. Acute psychotic disorder
b. Delusional disorder
c. Obsessive compulsive disorder
d. Paranoid schizophrenia
e. Schizoaffective disorder

Answer 74

c. Obsessive compulsive disorder

Question 75

A 28 year old man is prescribed regular medication for bipolar disorder. He has also been taking naproxen for a sports injury. He presents to the Emergency Department with ataxia, confusion and tremor. Which medication is most likely to have resulted in his symptoms?

a. Carbamazepine
b. Lithium
c. Olanzapine
d. Sertraline
e. Sodium valproate

Answer 75

b. Lithium

Question 76

A 25 year old woman is currently an informal inpatient on a mental health ward for management of a depressive episode. She has intent to end her life. She wants to leave the ward. She is deemed to have capacity to make a decision to leave hospital. Which is the next most appropriate step in management?

a. Allow her to self discharge
b. Detain her under the Deprivation of Liberty Safeguards
c. Detain her under the Mental Capacity Act
d. Detain her under the Section 2 of the Mental Health Act
e. Detain her under the Section 5(2) of the Mental Health Act

Answer 76

e. Detain her under the Section 5(2) of the Mental Health Act

Question 77

A 85 year old man in the memory clinic has concerns about being unable to recall what he ate for breakfast that morning or provide detail regarding his activities today and yesterday. He has difficulties concentrating. He has a tremor and poor balance. Which is the most appropriate initial step in his work-up?

a. Blood tests
b. CT brain
c. MoCA (Montreal Cognitive Assessment)
d. MRI brain
e. Neuropsychological testing

Answer 77

c. MoCA (Montreal Cognitive Assessment)

Question 78

A 22 year old woman in the Emergency Department describes an episode when she saw an unfamiliar man in her house at sunset. Her boyfriend, who was with her at the time, did not see this man in her house, but noted that she was disoriented to time and place. She reported no other difficulties at the time and she has no previous psychiatric history. Her AMTS is 6/10 and her temperature 37.9C. Investigations: GGT 11 IU/L (9 - 40), CRP 70 mg/L (<5); urine drug screen - negative for all substances. Which is the most likely diagnosis?

a. Alcoholic hallucinosis
b. Delirium
c. First episode psychotic disorder
d. Temporal lobe epilepsy
e. Young onset dementia

Answer 78

b. Delirium

Question 79

A 48 year old woman with Down syndrome has worsening memory impairment which is affecting her activities of daily living. Which is the most likely diagnosis?

a. Alzheimer’s disease
b. Frontotemporal dementia
c. Lewy body dementia
d. Pseudodementia
e. Vascular dementia

Answer 79

a. Alzheimer’s disease

Question 80

A 30 year old woman is assessed at the addictions treatment clinic for her heroin addiction, having never had treatment previously. Which is the most appropriate pharmacological treatment to initiate?

a. Diazepam
b. Disulfiram
c. Methadone
d. Naloxone
e. Naltrexone

Answer 80

c. Methadone

Question 81

A 30 year old woman attends the Urgent Treatment Centre after cutting her wrists superficially. She suffers from depression and is taking sertraline 50mg daily. Her partner walked out on her this morning. She feels distressed but her sister has offered to stay with her. She has previously cut her wrists with no threat to her life. She has no thoughts of suicide. She intends to attend her appointment with the psychiatrist tomorrow. Which is the next most appropriate step in management?

a. Arrange a Mental Health Act assessment
b. Call an ambulance
c. Call the duty psychiatrist for an urgent assessment
d. Give her the 24 hour mental health crisis number
e. Increase her dose of sertraline

Answer 81

d. Give her the 24 hour mental health crisis number

Question 82

A 24 year old paramedic is referred to see a psychiatrist by her GP. She reports that she has not been herself after attending a call last month when the patient ultimately died. She complains of low mood and difficulty falling asleep on most nights. Her appetite is not affected and she has not lost any weight. Blood test results including full blood count and thyroid function tests are unremarkable. Which is her most likely diagnosis?

a. Acute stress reaction
b. Adjustment disorder
c. Depressive episode
d. Generalised anxiety disorder
e. Post-traumatic stress disorder

Answer 82

e. Post-traumatic stress disorder

Question 83

A 25 year old man in the outpatient clinic is asked what prompted his GP to refer him. He responds as follows: ‘Doctor, that’s a difficult question. When I woke up at 7am, I thought about how much I’d like to make myself a boiled egg. I watched the news for a bit, and then found my favourite leather shoes. Later on I popped over to Tesco to get some fruit, and after that I came here to discuss a change in my medication’. Which thought disorder is exhibited by the man in this scenario?

a. Circumstantiality
b. Derailment (loosening of associations)
c. Flight of ideas
d. Pressure of speech
e. Tangentiality

Answer 83

a. Circumstantiality

Question 84

A 35 year old man in General Practice has obsessive compulsive disorder. He has not engaged with psychological treatment. Initiation of which class of medication is most appropriate in this scenario?

a. Acetylcholinesterase inhibitor
b. Benzodiazepine
c. Monoamine oxidase inhibitor
d. Selective serotonin reuptake inhibitor
e. Tricyclic antidepressant

Answer 84

d. Selective serotonin reuptake inhibitor

Question 85

The mother of a 7 year old boy is concerned that he has always struggled to focus in class, wait for his turn and has lots of energy in comparison to his peers. He has few friends and has only been in one physical fight in his life. Which is the most likely diagnosis?

a. Attention deficit hyperactivity disorder
b. Conduct disorder
c. Depression
d. Psychosis
e. Social anxiety

Answer 85

a. Attention deficit hyperactivity disorder

Question 86

A 34 year old woman with borderline personality disorder has taken a spontaneous paracetamol overdose after breaking up with her boyfriend. She had texted her friend afterwards because she worried about who would care for her children. She had locked herself in the bathroom before taking the overdose but had not stocked up on tablets. Which of the following would cause the most concern?

a. Admitting the overdose was a spontaneous decision
b. Expressing worry about who would look after her children if she was not around
c. Locking the bathroom door before taking the overdose
d. Not stocking up on tablets
e. Texting her friend after taking the overdose

Answer 86

c. Locking the bathroom door before taking the overdose

Question 87

A 45 year old man in General Practice is requesting help with his alcohol consumption. He drinks one bottle of vodka a day. He begins shaking as if he has not had an alcoholic drink first thing in the morning. Previously, when he tried stopping drinking suddenly 2 years ago, he had a seizure. Which is the most appropriate management plan?

a. Offer self-help guides
b. Prescribe a reducing dose of chlordiazepoxide
c. Prescribe acamprosate
d. Prescribe thiamine
e. Refer for inpatient detoxification

Answer 87

e. Refer for inpatient detoxification

Question 88

A 55 year old man attends for a routine health review. He was seen on a few occasions last year after he was made redundant from his job as an IT technician. At the time he had low mood, anhedonia, insomnia and hopelessness, which all resolved after he found a new job. Which is the most likely diagnosis?

a. Adjustment disorder
b. Bipolar affective disorder
c. Personality disorder
d. Post-traumatic stress disorder
e. Severe depressive disorder

Answer 88

a. Adjustment disorder

Question 89

A 33 year old woman takes omeprazole, paroxetine, aripiprazole, and zopiclone for gastro-oesophageal reflux and bipolar affective disorder. She also takes the combined oral contraceptive pill. Her annual blood test show: sodium 135 mmol/L (135 - 145), potassium 4.2 mmol/L (3.5 - 5.3), urea 5.1 mmol/L (2.5 - 7.8), creatinine 63 umol/L (60 - 120), eGFR 90 (>60) and prolactin 622 UI/L (100 - 500). Which medication is most likely responsible?

a. Aripiprazole
b. Combined oral contraceptive pill
c. Omeprazole
d. Paroxetine
e. Zopiclone

Answer 89

a. Aripiprazole

Question 90

A 63 year old man is in General Practice for his annual medication review. His past medical history includes ischaemic heart disease, depression and rheumatoid arthritis. He is taking citalopram (10 mg once daily), bisoprolol (5 mg once daily), atorvastatin (40 mg once daily), methotrexate (15 mg once weekly) and aspirin (75 mg once daily). His blood results are as follows: sodium 130 mmol/L (135 - 145), potassium 4.2 mmol/L (3.5 - 5.3), urea 4.2 mmol/L (2.5 - 7.8), creatinine 93 umol/L (60 - 120). Which of his medications is the most likely cause of this derangement?

a. Aspirin
b. Atorvastatin
c. Bisoprolol
d. Citalopram
e. Methotrexate

Answer 90

d. Citalopram

Question 91

A 17 year old girl in the Emergency Department has experienced a seizure. She appears confused and fatigued, and has an irregular heart rhythm. Her blood pressure is 170/90 mmHg. Her mother reports that she has anorexia nervosa and her father has been trying to force feed her. What diagnosis would most likely explain her clinical presentation?

Answer 91

Refeeding syndrome

Question 92

A 56 year old man is brought to the Emergency Department by ambulance after he was found collapsed in a park. His pupils are constricted and his respiratory rate is 6 breaths per minute. What emergency medication should be administered in this scenario?

Answer 92

Naloxone

Question 93

A 21 year old man with a history of drug use is detained under the Mental Health Act (1983) for treatment of an acute psychotic episode. He has been administered an initial dose of zuclopenthixol depot 2 days ago. His urine drug screen is positive for cannabis. He is confused, has muscle rigidity, fever and hyporeflexia. His temperature is 38.4C, pulse rate 113 bpm, BP 135/80 mmHg, respiratory rate 26 breaths per minute and oxygen saturation 96% breathing air. What is the most likely cause for the change in presentation?

Answer 93

Neuroleptic malignant syndrome from depot

Question 94

A 75 year old man with recurrent depressive disorder stopped taking his medication 1 month ago. He now has significant low mood and suicidal thoughts. He is admitted informally following an apparent attempt to hang himself. His wife died of cancer 2 years ago and he has no children. What level of observation should be provided by the ward nursing staff in this scenario?

Answer 94

1:1

Question 95

A 30 year old woman is admitted to the Mental Health Unit. She has reportedly been spending her savings on expensive items of clothing. Her named nurse reports that she hardly sleeps at night and seems unable to settle down. She is overfamiliar and labile in mood. A urine drug screen is negative for all substances and all blood test parameters are within normal limits. What is the likely diagnosis?

Answer 95

Manic episode

Question 96

A 76 year old man who lives independently is admitted to the mental health unit with a severe depressive episode. He was managed in the community with multiple antidepressants at various times, but none have really benefited him. He completed a course of ECT treatment a few days ago. His family members visit him on the ward but he is unable to recognise them. What type of memory impairment is demonstrated?

Answer 96

Retrograde amnesia

Question 97

A 35 year old woman who is 7 weeks postpartum, presents with low mood, anhedonia, poor energy levels, insomnia and fleeting suicidal thoughts. She has no previous history of mental illness. She is breastfeeding. Initiation of what medication class is most appropriate in this scenario?

Answer 97

Selective sertraline re-uptake inhibitor

Question 98

A 24 year old man is brought to the Emergency Department by police. A neighbour had reported him shouting in his house, following which, he ran onto the street and began throwing rocks at passing cars. The police arrested him and brought him to hospital. Under what section of the Mental Health Act (1983) was he most likely detained?

Answer 98

Section 136

Question 99

A 30 year old male with paranoid schizophrenia has been treated unsuccessfully with aripiprazole and later, olanzapine. He has ongoing delusions that his family and nursing staff are poisoning his food and medication. He hears two men arguing and commenting on his actions. What is next most appropriate pharmacological treatment option?

Answer 99

Clozapine

Question 100

A 61 year old man with alcohol dependence is brought to the Emergency Department by ambulance following concerns by neighbours. He presents with confusion and disorientation. He is irritable, tremulous and sweating. He appears to be responding to external visual stimuli. His temperature is 37.9C, pulse rate 125 bpm, BP 140/95 mmHg, respiratory rate 20 breaths per minute and oxygen saturation 95% breathing air. His breathalyser reading is 80 microgram alcohol / 100 mL of breath (legal limit for drivers <35). What is the most likely diagnosis?

Answer 100

Acute alcohol intoxication

Question 101

A 13 year old boy attends the child psychiatry clinic with his parents, who describe a 7 month history of overeating. He frequently rummages through the cupboards at odd times of the day. He has said at times that he feels fat. His BMI is 18.5 kg/m2 (just under the 50th centile for his age). He has calluses on his knuckles. He performs well academically. What is the most likely diagnosis?

Answer 101

Bulimia

Question 102

A 20 year old medical student has become increasingly isolated and has stopped attending lectures for the past 7 months. Concerns have been raised by his friends that he has been locking himself in his room and talking to himself. He believes that the government is spying on him and trying to steal his intelligence. He reports hearing female voices commenting on his actions. What is the most likely diagnosis?

Answer 102

Schizophrenia

Question 103

A 20 year old woman in the outpatient clinic has sudden episodes of palpitations, shortness of breath, sweating, chest pain and dry mouth. These episodes started 6 months ago, occur randomly and last for about 15 minutes. Education and lifestyle modification advice have not been helpful. What is the most appropriate next step in regards to her management?

Answer 103

Sertraline (SSRI, SNRI, TCA)

Benzodiazepines shouldn’t be prescribed for panic disorder

Question 104

A 55 year old man in the outpatient clinic has been experiencing frequent thoughts of jumping onto the train tracks during his daily commute. This is very distressing for him as he does not consider himself to be suicidal. He has stopped taking the train and instead takes three buses to work, adding 1 hour to his journey time. He has received a warning for attending late. What is the most likely diagnosis?

Answer 104

OCD

Question 105

A 32 year old woman attends her GP surgery for her 6 week postnatal check. She has low mood, feels exhausted, is unable to sleep and is struggling to bond with her baby. She has lost her appetite and looks dishevelled. Her partner stated that she worries excessively about her baby. She has no previous psychiatric history. What is the most likely diagnosis?

Answer 105

Postpartum depression

Question 106

A 20 year old man has never been able to hold down a job for longer than a few months at a time. His relationships have also been affected by his symptoms. He has recently been diagnosed with ADHD by his psychiatrist. What medication would the psychiatrist most likely recommend in this scenario?

Answer 106

Methylphenidate

Question 107

An 18 year old girl in General Practice has had no periods for the previous 4 months. She had the contraceptive implant inserted 2 years ago. She reports missing meals as she has been stressed for her university exams. She admits to making herself vomit occasionally when she is stressed. Her temperature is 36.8C, pulse rate 65 bpm, BP 109/70 mmHg, BMI 17.5 kg/m2. A pregnancy test is negative. What is the most likely diagnosis?

Answer 107

Anorexia nervosa

Question 108

A 55 year old woman in General Practice is in a tearful state and reports feeling low. She advises that she gets cold easily and has been gaining weight. What investigation will likely be discriminatory in this scenario?

Answer 108

Thyroid function tests

Question 109

A 28 year old woman in General Practice is agitated. She had a healthy baby boy via normal spontaneous vaginal delivery 7 days ago. The birth and pregnancy were uncomplicated. She mentions her thoughts have been racing for the last few days and she has been hearing a voice telling her that her food is being poisoned by her husband. What is the most likely diagnosis?

Answer 109

Puerperal psychosis