Qm

Question 1

woman believes doctor in love with her

Answer 1

De Clerambault’s syndrome, otherwise known as erotomania, is a delusional disorder in which the patient has a specific, fixed, false belief that someone else is in love with them

Question 2

Capgras delusion

Answer 2

is the fixed, false belief that a close relative or partner has been replaced by an impostor,

Question 3

Fregoli

Answer 3

The Fregoli delusion is a rare misidentification syndrome where the individual believes that different people are, in fact, the same person in disguise.

Question 4

Cotards

Answer 4

person is dead

Question 5

45M, confusion and recurrent falls. He remembered taking lithium but could not name the other medications he was taking.
Examination revealed dysdiadochokinesia bilaterally.
Which other medicine could have contributed to his symptoms?

Answer 5

Thiazides and thiazide like diuretics - Indapamide

This patient may be presenting with signs of lithium toxicity, which can include confusion, seizures, cerebellar symptoms (such as the ataxia described here), tremor (however, a mild tremor can be seen in 25% of patients taking lithium), visual disturbances, or arrhythmias.

Thiazide and thiazide-like diuretics (such as indapamide) reduce lithium clearance, increasing its serum concentration and the risk of toxicity. Other anti-hypertensives that can interfere with lithium clearance include ACE inhibitors and angiotensin receptor blockers.

Question 6

58F, 2-year history of repetitive handwashing, intrusive thoughts of the surroundings being contaminated with viruses,

She finds these thoughts and actions distressing and almost irresistible. She is always late to her social gatherings with her friends, as she spends most of her time washing her hands.

She has a past history of hypertension and myocardial infarction.
Which is the most appropriate pharmacotherapy?

Answer 6

sertraline - moderate to severe OCD

Only certain SSRIs, including fluoxetine, fluvoxamine, paroxetine, sertraline, and citalopram, are used to treat OCD, with citalopram being prescribed off-label.

Question 7

type of tremor in lithium toxicity

Answer 7

coarse

Question 8

previous depressive presenting as manic mx

Answer 8

stop antidepressant, start risperidone (atypical antipsychotic)

Question 9

lithium toxicity treatment

Answer 9

In lithium toxicity, treatment with IV fluids and urine alkalization helps to enhance lithium excretion and reduce its concentration in the blood.

Question 10

short history of psychotic symptoms always do

Answer 10

toxicology

only MRI head if neurological symptoms, raised ICP

Question 11

schizophrenia hearing voices treatment

Answer 11

Atypical antipsychotics like risperidone are effective for managing acute psychosis, addressing both positive and negative symptoms of schizophrenia.

Question 12

lithium levels above 3.5mmol/L and severe symptoms most important step

Answer 12

Severe lithium toxicity, characterized by symptoms such as tremors, confusion, and seizures, requires urgent haemodialysis to reduce serum levels and prevent sustained seizure activity.

Question 13

A 45-year-old woman presents with a 3-week history of persistent low mood after she was made redundant from her job as a financial analyst. She describes feeling low for most of the day, nearly every day and reports associated symptoms including significant weight loss, insomnia, difficulty concentrating on job applications, and feeling excessively guilty.

Dx?

Answer 13

Major depressive disorder
Major depressive disorder is diagnosed when an individual experiences five or more typical symptoms over a period of at least 2 weeks.

These symptoms include a depressed mood, markedly diminished interest or pleasure usual activities, weight loss or gain, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue or loss of energy, feelings of worthlessness or excessive guilt, diminished ability to think or concentrate, and recurrent thoughts of death or suicide.

Question 14

Which of the following blood test results may be seen in a patient with purge-type bulimia?

Answer 14

Hypokalaemia with metabolic alkalosis

Hypokalaemia with metabolic alkalosis is seen in patients who have frequently been vomiting either due to bulimia or due to an organic cause such as norovirus. Vomiting induces the renin–angiotensin–aldosterone steroid (RAAS) system to activate, retaining sodium, bicarbonate and water and expelling potassium. The use of diuretics also further reduces levels of potassium in the body, leading to a hypokalaemic state with metabolic alkalosis.

Question 15

A 50-year-old man with a history of chronic alcoholism presents with confusion, hallucinations, tremors, and agitation after abruptly stopping drinking alcohol.
According to NICE guidelines, which of the following is the most appropriate initial management for his condition?

Answer 15

Lorazepam
The most appropriate initial management of delirium tremens (DTs) is benzodiazepines to manage symptoms of alcohol withdrawal and supportive care including hydration, electrolyte management, and nutritional support. NICE recommend lorazepam or carbemazepine as first line options.

Question 16

A 57 year old man is referred to the neurology clinic with memory problems. He was, until recently, a lawyer. He has stopped working after being disciplined at work for inappropriate behaviour and he was recently given a caution by the police for stealing chocolate from a shop.
Which of the following signs would he be most likely to exhibit?

Answer 16

Constructional apraxia
This patient most likely has frontotemporal dementia, a relatively rapidly progressive dementia affecting younger people. Patients have marked personality change and MRI shows significant atrophy of the frontal and temporal lobes. Constructional apraxia i.e. failure to draw interlocking pentagons may be a key feature in the early stages

Question 17

A 72 year old man presents with episodes of urinary incontinence and difficulty in walking, with some rigidity of his movements. His daughter has reported that both are very unusual, as her father was previously completely independent and fit and well. She also reports concerns about his memory and on formal testing his mini-mental state examination (MMSE) is 13/30.
CT head demonstrates significant enlargement of the ventricles, with no sulcal atrophy.
What is the most effective management for this patient?

Answer 17

urgical insertion of a cerebrospinal fluid shunt
This gentleman is suffering from normal pressure hydrocephalus and is displaying the classic triad of gait disturbance, urinary incontinence and dementia. Surgical insertion of a ventriculoperitoneal shunt is the mainstay of treatment and 70-90% of patient gain a lasting benefit post-operatively

Question 18

A 30 year old woman presents to the GP with low mood following the birth of her first child three months ago. Since her husband’s return to work last month she has had difficulty coping. She reports poor appetite and low energy levels, and only manages to get out of bed to breastfeed and take care of the baby. She becomes tearful during the consultation. When asked if she has thoughts of harming herself or the baby, she is visibly shocked and responds ‘never!’
Which of the following is the most appropriate intervention?

Answer 18

Referral for cognitive behavioural therapy (CBT)
This patient is experiencing mild to moderate postpartum depression, which is managed the same as depression in other circumstances. Options include CBT, starting a Selective Serotonin re-uptake inhibitor (SSRI), or both - but there is a higher threshold for starting SSRIs post-partum due to contamination of breastmilk, and so are reserved for more severe cases

Question 19

A 50 year old man attends the GP for a mental health review. He was diagnosed with moderate depression two months ago after losing his job and has been taking Sertraline since then. He tells you he feels much better now, he is eating and sleeping well, and that he is finally ready to stop taking medication. He no longer has thoughts of self-harm, and he has started looking for work. You concur that his mood is much improved in clinic today.
What is the most appropriate advice to give regarding cessation of treatment?

Answer 19

Continue Sertraline for a further six months
NICE recommend that antidepressants should be continued for at least six months after patients recover. This is to reduce the risk of relapse. As the patient has been taking Sertraline for two months, and reports improvement in mood today, he should continue to take it for at least six more months. If improved mood is sustained, treatment can then be stopped

Question 20

is increased sociability a mania symptom

Answer 20

no

Question 21

OCD vs obsessive compulse personality disorder

Answer 21

OCD is distressing and associated with significant anxiety.

OCPD is enjoyable

Question 22

refeeding syndrome ECG and why

Answer 22

In refeeding syndrome, patients are at risk of low phosphate, magnesium and potassium levels, as well as hyperglycaemia. Prominent U waves are a feature of hypokalaemia and may therefore be seen in refeeding syndrome.

Question 23

Biochemical abnormalities found in anorexia nervosa include:

Answer 23

Biochemical abnormalities found in anorexia nervosa include:
Low levels of sex hormones: FSH, LH, testosterone and oestrogen
Normal T4, low T3
Low levels of potassium, calcium and magnesium
Metabolic alkalosis
High levels of cortisol

Question 24

A 32 year old lady presents to the GP to review her medication. She was started on sertraline two months ago for Obsessive Compulsive Disorder (OCD) but now feels better and is keen to stop her medication. She is on 50 mg of sertraline OD, and has no known allergies.
What would be the most appropriate management plan?

Answer 24

continue for 12 months as OCD (not 6 like depression)

Question 25

A 70-year-old woman with suspected Alzheimer's disease is seen in a geriatric psychiatry clinic. She is accompanied by her husband, who reports increasing concerns over her memory, but says she is generally quite easy to take care of. They both deny any issues with low mood. She scores 18/30 on the mini-mental state examination. She is commenced on a new medication for these symptoms. Which of the following is the most likely mechanism of action of the new medication?

Answer 25

Acetylcholinesterase inhibitor The Mini-Mental State Examination (MMSE) is used to rate the severity of Alzheimer's disease (AD). A score of 21-26 indicates mild AD, 10-20 indicates moderate AD and <10 indicates severe AD. This patient, therefore, has moderate AD. NICE guidelines recommend three acetylcholinesterase inhibitors (donepezil, rivastigmine and galantamine) as first-line treatment for mild-moderate AD. Memantine is recommended in patients with mild-moderate AD who do not tolerate acetylcholinesterase inhibitors or in those in whom they are contraindicated. It is recommended as a first-line treatment in patients with severe AD.

Question 26

recognised complication of lithium

Answer 26

One of the recognized complications of lithium therapy is nephrogenic diabetes insipidus, now referred to as arginine vasopressin resistance (AVP-R).

Question 27

first line for severe alzheimers med and SE

Answer 27

memantine - constipation

Question 28

A 36-year-old woman is seen by her GP with ongoing concerns around her abdominal pain, which has been present for the last 2 years. The pain is present all of the time, however she notes it can become worse in times of psychological stress. She has undergone extensive physical examinations, and investigations including blood tests and a CT thorax, abdomen and pelvis, which have all been normal. Although she is not particularly concerned about any serious underlying cause, she finds the pain disrupts her social life and can make it difficult to concentrate at work. She is otherwise well, with no medical conditions other than depression, for which she takes sertraline. Which of the following is the most likely underlying diagnosis?

Answer 28

Somatoform disorder Somatoform disorder describes the presence of physical symptoms that cannot be explained by a physical medical condition. It is an unconscious process, and patients are not fabricating their symptoms. Common presenting symptoms are gastrointestinal symptoms, fatigue, weakness, musculoskeletal symptoms and, as in this patient's case, abdominal pain.

Question 29

schizoid vs schizotypal

Answer 29

In schizoid personality disorder, patients show a lack of interest in others, apathy and a lack of emotional breadth. In schizoTYPAL - unusual social behaviour, bizarre or magical thinking and distorted perceptions

Question 30

What section of the Mental Health Act 1983 can be used by a hospital doctor to detain patients for up to 72 hours when they are attempting to self discharge?

Answer 30

5(2)

Question 31

opioid substitution therapy

Answer 31

NICE states that both methadone or buprenorphine are equally effective as an opioid substitution therapy; however, there may be specific reasons for choosing one above the other. For example, if a patient has had a previous overdose on methadone, then buprenorphine should be given. However, if both drugs are equally suitable, as they appear to be in this patient, then methadone should be prescribed first line.

Question 32

An 80-year-old man is brought to the GP by his wife due to concerns about his behaviour. She reports a decline in his memory over the last six months and is concerned that he sees animals which are not there. Opticians have recently reported that his vision is normal. She also says he moves around a lot in bed at night and has been walking more slowly than usual. He has had several recent falls. The patient has a history of hypertension and myocardial infarction. On assessment, there is a resting hand tremor but no focal neurological deficits.

Answer 32

dementia with lewy bodies

Question 33

A 36 year old man comes to the GP surgery with insomnia. He says it has been ongoing since he was the victim of a violent mugging 2 weeks ago. He received minor injuries that were treated at the scene by paramedics. Since then, he has felt extremely anxious and has been unable to sleep. He has avoided the park near his house where the crime occurred as when he walked past it he felt incredibly distressed. He says he cannot remember the mugging, feeling as if it was “a dream” and talks about feeling 'numb and unreal' since the incident. Which of the following is the most likely diagnosis?

Answer 33

acute stress reaction as under a month

Question 34

A 15 year old physically well girl presents to A&E with new seizures and confusion. She is emotionally labile without obvious reason. She has no personal or family history of mental illness. She has no history of epilepsy or febrile seizures and regains full consciousness between seizures. What is the most appropriate next step?

Answer 34

full neuro exam query encephalitis

Question 35

A 75-year-old man presents to his GP with a 12-month history of gradual forgetfulness, including leaving the door unlocked and the gas on after cooking. His wife is concerned, though she feels his behaviour does not put them at risk. He has a history of depression but no recent mood issues. He occasionally struggles with word-finding but there has been no significant impact on daily functioning. Neurological examination is normal. He is referred to a psychiatrist who diagnoses him with mild Alzheimer's disease and starts him on first-line pharmacological therapy. Which of the following is most likely to be a side effect of this therapy?

Answer 35

Diarrhoea This man has been diagnosed with mild Alzheimer's disease and started on first-line pharmacological therapy, which will be an acetylcholinesterase inhibitor such as Donepezil, Galantamine or Rivastigmine. These drugs cause cholinergic side effects such as diarrhoea, nausea and vomiting, bradycardia, increased salivary production and urinary incontinence

Question 36

sedation in pt with Parkinson's

Answer 36

In a patient with a history of Parkinson's disease or Lewi-Body dementia, sedation with a benzodiazepine is preferred to avoid the extra-pyramidal side effects of anti-psychotics such as Haloperidol eg IM Lorazepam

Question 37

‘I took the bus and the train, the problem is it rained yesterday so I was never very good at scrabble and I suppose my favourite food is lasagne because the neighbour’s dog kept me up all night!’

Answer 37

Knight's move thinking Named after the way the knight moves in chess, this thought disorder is characterised by illogical leaps between unconnected ideas. It is also known as loosening of associations not word salad as not individual words

Question 38

Ct findings in normal pressure hydrocephalus (wet, wobbly and weird)

Answer 38

Enlarged ventricles and absent sulci seen on CT brain scan

Question 39

A 78-year-old woman is on the ward after a hemicolectomy. She is not rousable, is flushed and has excoriations over her hands. She has decreased bowel sounds and a respiratory rate of 8 breaths per min. What is the best treatment?

Answer 39

naloxone boluses titrated

Question 40

symptoms of clozapine toxicity e.g. during infection

Answer 40

– confusion, drowsiness, ataxia and tachycardia.

Question 41

A 26-year-old man presents to the Emergency Department with a 3-hour history of agitation and diaphoresis. He does not have chest pain, breathlessness or headache. He has a history of severe depression with psychotic symptoms. He is taking sertraline and olanzapine, with no recent dose adjustments. He admits to taking amphetamines for the first time today. His observations are as follows: Temperature 38.5 °C Blood pressure 160/100 mmHg Heart rate 112 bpm Respiratory rate 22 breaths/min Chest and cardiovascular examinations show no abnormalities. Neurological examination reveals rigidity, clonus and hyperreflexia. His pupils are dilated bilaterally. What is the most likely diagnosis?

Answer 41

Serotonin syndrome This man has clinical features of serotonin syndrome – restlessness, diaphoresis, clonus, hyperthermia, rigidity, hyperreflexia, etc. Sertraline (a selective serotonin-reuptake inhibitor, SSRI) and amphetamines both increase serotonergic transmission in the brain, which can precipitate serotonin syndrome. NMS would be gradual onset, with normal pupils, hyporeflexia and no clonus

Question 42

what is acamprosate for

Answer 42

alcohol dependance

Question 43

paranoid delusions and auditory hallucinations, together with symptoms of agitation and diaphoresis. He is having pyrexia and tachycardia. He is taking acamprosate for alcohol dependence. The most likely diagnosis and Mx here is

Answer 43

delirium tremens. This is likely to occur when a patient with alcohol dependence is abstinent from alcohol for a few days. The first-line treatment for this medical emergency is oral lorazepam. Lorazepam is a short-acting benzodiazepine. If oral medication is declined or the symptoms persist, give parenteral lorazepam or haloperidol. This is an off-label use of lorazepam and haloperidol.

Question 44

A 26-year-old woman presents with a 2-month history of amenorrhoea. She previously had regular menstrual cycles. She is sexually active and uses barrier contraception but admits that she has reduced libido. She has gained over 3 kg in weight over the past 3 months. She was diagnosed with bipolar affective disorder 3 months ago and is taking risperidone. She denies having symptoms of mania or depression. Her urine pregnancy test is negative. Which is the most appropriate investigation to confirm the diagnosis?

Answer 44

Prolactin This woman likely has hyperprolactinaemia secondary to the second-generation antipsychotic risperidone, given its temporal association. Symptoms of hyperprolactinaemia include amenorrhoea or oligomenorrhoea, decreased libido, galactorrhoea, infertility and osteoporosis. Not all women with hyperprolactinaemia will have galactorrhoea. Although first-generation antipsychotics are generally more likely to cause hyperprolactinaemia, risperidone is also a notable cause.

Question 45

do you have to vomit to have bulimia

Answer 45

no - Notably, compensatory behaviours do not have to include self-induced vomiting for a diagnosis of bulimia nervosa to be made.

Question 46

abnormalities of flow and coherence

Question 47

manic person saying I could be director of my company from associate very soon - is this a grandiose delusion or something else?

Answer 47

overvalued ideas - slightly delusional but not out of the realms of possibility

Question 48

ecstasy OD Mx

Answer 48

Ecstasy (MDMA, 3,4-Methylenedioxymethamphetamine) poisoning management is supportive. Dantrolene may be used for hyperthermia if supportive measures fail. If serotonin syndrome develops, cyproheptadine and chlorpromazine may also be considered for more severe cases.

Question 49

A 50 year old male presents to the general practitioner with low mood and difficulty coping since he was made redundant 4 months ago. He admits to drinking 40 units of alcohol per week. He would like help on cutting down his drinking. He scores 13 on the AUDIT questionnaire (indicating harmful drinking). The patient is otherwise fit and well. The GP judges that there are no risks to the patient or others. Which of the following treatment options should be offered first line?

Answer 49

Cognitive behavioural therapy This is the correct answer. NICE guidelines recommend that for harmful drinkers and those with a mild alcohol dependence, psychological management (such as CBT or behavioural therapies) should be offered first line Disulfiram is an option in patients undergoing intensive community programmes for alcohol dependence, following successful withdrawal. It is not recommended as first line therapy for harmful drinking Nalmefene may be used to reduce alcohol consumption but only in patients with a high drinking risk level (>60g per day for men and >40g per day for women) and should be prescribed in conjunction with psycho-social support not assisted withdrawal

Question 50

A 34 year old man with paranoid schizophrenia was started on Risperidone 6 months ago. He presents to his GP complaining of development of breast tissue, loss of libido and erectile dysfunction and blood tests show hyperprolactinaemia. Which medication is the most appropriate to change to?

Answer 50

Aripiprazole This man presents with symptoms in keeping with hyperprolactinaemia. This is a side effect seen in some patients prescribed antipsychotics, as they act as dopamine receptor antagonists, stimulating the production of prolactin. If the patient complains of clinical features of hyperprolactinaemia and blood results support this, it is necessary to stop the responsible agent (in this case Risperidone) and change to an alternative antipsychotic. Aripiprazole is one antipsychotic with a much lower risk of inducing hyperprolactinaemia

Question 51

when is assisted alcohol withdrawal recommended

Answer 51

Assisted withdrawal with chlordiazepoxide Assisted withdrawal is recommended for patients who drink over 15 units of alcohol per day and/or those who score over 20 on the AUDIT questionnaire. This patient does not meet the criteria for requiring assisted withdrawal

Question 52

how is lithium toxicity managed

Answer 52

Discontinuation of lithium and supportive care benzodiazepines to manage agitation and seizures can be used

Question 53

what does perceptual abnormality mean

Answer 53

4. Perceptual abnormality - doesn’t mean delusions / illusions, means other senses hallucinations

Question 53

A 38-year-old female is brought to A&E by a friend after being found disorientated and agitated outside her home. Her friend reports that she has 'not been herself' for over a fortnight. Neurological examination reveals dystonia, gait ataxia and dysdiadochokinesia. A lumbar puncture is performed with CSF demonstrating lymphocytic pleocytosis. Given the most likely diagnosis, what is the most appropriate treatment?

Answer 53

Autoimmune encephalitis, characterised by acute mental disturbance and neurological abnormalities, is initially treated with steroids and intravenous immunoglobulins to suppress inflammation.

Question 54

amitriptylline OD features

Answer 54

Amitryptilline is a tricyclic antidepressant (TCA) used to treat depression. Clinical features of TCA overdose include confusion, seizure, tachycardia, hypotension and dilated pupils (mydriasis). In addition, TCA overdose can cause ECG changes (eg. prolonged QRS duration and QTc interval) and metabolic acidosis. The mainstay management of TCA overdose is supportive care and sodium bicarbonate.

Question 55

GH in anorexia

Answer 55

raised

Question 56

cholesterol in anorexia

Answer 56

hypercholesterolaemia

Question 57

name for lewy bodies

Answer 57

Alpha-synuclein cytoplasmic inclusions

Question 58

experiencing auditory hallucinations which provide running commentary, as well as thought insertion, for more than one month, mx

Answer 58

experiencing auditory hallucinations which provide running commentary, as well as thought insertion, for more than one month, fitting diagnostic criteria for paranoid schizophrenia. This is treated first-line with atypical antipsychotics such as Risperidone

Question 59

brain matter in alzheimers

Answer 59

beta-amyloid plaques and neurofibrillary tangles made of tau protein.

Question 60

FTD often presents with

Answer 60

constructional apraxia, which is difficulty in performing tasks requiring spatial awareness and planning, such as copying complex shapes or building objects.

Question 61

what MH conditions predispose to anorexia

Answer 61

A personal history of OCD, anxiety or depression may predispose this woman to Anorexia Nervosa, but there is no evidence to suggest a link between schizophrenia and Anorexia Nervosa A history of dieting and other weight-control methods is associated with the development of binge eating and other eating disorders.

Question 62

potassium and WCC in bulimia

Answer 62

low

Question 63

NMS presentation, diagnosis and management

Answer 63

This patient has neuroleptic malignant syndrome (NMS). Neuroleptic malignant syndrome is a life-threatening complication of taking dopamine antagonist medication. Most cases start within 4-14 days of commencing the medication, but some cases may occur many years after taking the same drug, at the same dose. It is likely this patient has been started on an antipsychotic medication, which has triggered his NMS. Clinical signs and symptoms include fever, muscle rigidity, confusion, rhabdomyolysis (hence the raised creatine kinase and subsequent electrolyte derangements such as hyperkalaemia and hypocalcaemia), metabolic acidosis, autonomic lability, and a raised white cell count. It takes up to 2 weeks to recover after stopping the medication. Treatment is with supportive measures (fluids, keeping the patient cool), dopamine agonists such as bromocriptine, or dantrolene.

Question 64

A 32 year old woman with a background of long-standing schizophrenia is reviewed by her GP. She has had some bloods test taken as she was feeling unwell and theses have shown a neutrophil count of 0.4 and a CRP of 55. The rest of her blood tests are within the normal range. What medication is she likely to be taking that is likely to have caused her neutropenia?

Answer 64

Clozapine This is the correct answer. Agranulocytosis or neutropenia occurs in up to 0.8% of patients on clozapine. It is most common in the first 6-12 weeks. Neutrophil monitoring needs to be done every week during the first 6 months of clozapine therapy and becomes less frequent thereafter. A neutrophil count of less than 0.5 should lead to discontinuation of clozapine.

Question 65

37-year-old male is arrested following a break-in. He is very agitated in his cell and has several large cuts on his hands from smashing a window. He has a record with the police with incidents from as young as 13, where he was cautioned for reckless behaviour involving bikes and other crimes such as petty theft and grievous bodily harm (GBH). He was excluded from school at age 15 after threatening violence against a staff member. He has also been arrested for drunk driving, each time showing no remorse or concern that other members of the public could have been hurt. What is the preferred management choice for the likely diagnosis?

Answer 65

Group-based Cognitive Behavioural Therapy (CBT) Antisocial personality disorder is associated with conduct disorder. Conduct disorder is commonly diagnosed before 18-years old. There is usually a history of vandalism/aggression/violence/stealing or expulsion from school. Adults can only be diagnosed with antisocial personality disorder if there is a history of childhood conduct disorder and they fulfil three of seven criteria after the age of 15, including engaging in illegal activities (driving under the influence), impulsiveness, repeated aggression (GBH) and a lack of concern for their own or others' safety. First line management options include group-based CBT, and generally pharmacological management is not advised due to lack of evidence. Dialectical Behavioural Therapy (DBT) DBT is more effective for Borderline Personality Disorder, particularly in patients with emotional dysregulation and self-harming behaviours. It is not the first-line treatment for ASPD.

Question 66

A 63 year old man is seen in GP following a decline in his memory. His wife states that he has forgotten several important appointments in the past few months and recently got lost on the way home. Which of the following should be part of an initial screening to investigate this patients symptoms?

Answer 66

Thyroid function tests (TFTs) This is correct. TFTs as well as other blood tests, including FBC, ESR, CRP, U&E, Ca, HbA1c, LFTs, serum B12 and folate, are used as screening tests to look for other identifiable causes of confusion.

Question 67

His most recent CT head from a hospital admission 5 months ago showed evidence of small vessel disease and generalised areas of atrophy.

Answer 67

commence donepezil - mixed dementia, generalised atrophy

Question 68

phosphate in reseeding syndrome

Answer 68

low - Rapidly increasing insulin levels lead to shifts of potassium, magnesium and phosphate from extracellular to intracellular spaces

Question 69

A 24 year old man presents to A&E reporting that MI5 are following him and monitoring his activity. He believes that the authorities are putting thoughts into his mind and that they are controlling his actions. His sister accompanies him, saying he has been complaining of this for the last 6 weeks and is becoming withdrawn from his family and friends. What is the mechanism of action of the treatment of his condition?

Answer 69

Dopamine receptor antagonism This man presents with symptoms of paranoid schizophrenia (persecutory delusions, thought insertion and passivity phenomena, social withdrawal). He should be offered an atypical antipsychotic medication such as Risperidone or Olanzapine. Most antipsychotics act as antagonists at multiple receptor sites but the psychotic symptoms are reduced by dopamine receptor antagonism

Question 70

weird symptom of lithium toxicity

Answer 70

visual disturbance

Question 71

A 24-year-old student is brought to the GP by his boyfriend, concerned about his strange behaviour. For 3 weeks, he has been staying up all night working on a 'transformative' project, becoming irritable and snapping when questioned When alone, the student claims to have a 'solution' to global warming and admits spending heavily on project materials. He denies drug use but is irritable and agitated throughout the consultation. Reviewing his notes, you note that he was seen by your colleague last year following a paracetamol overdose. She noted low mood and insomnia at this time but there was no subsequent follow up. Given the likely diagnosis, what is the most appropriate acute management?

Answer 71

risperidone - less likely to give EPS than haloperidol

Question 72

An 80-year-old man is diagnosed with Alzheimer's dementia in the memory clinic after extensive clinical evaluation, cognitive examination and MRI brain scan. His past medical history includes chronic diarrhoea, hypertension, heart failure and urinary urge incontinence. His ECG shows evidence of QT prolongation which appears to be longstanding. Which of the following is the most appropriate first line management of his Alzheimer's?

Answer 72

Cognitive stimulation therapy The fact this patient has evidence of QT prolongation makes the prescription of anti-cholinesterase inhibitors unsafe. Also, they might make his diarrhoea and urge incontinence worse.

Question 73

A 71-year-old woman with a history of dementia and multiple comorbidities has been admitted following a fall. She has recently been started on treatment for depression. Since starting this medication, she has been complaining of dry eyes and dizziness, and her carers note that she has been slightly more confused than usual. A physical examination reveals no concerning features, and her initial blood tests are normal. There is no postural drop in blood pressure. A CT scan of her brain is also normal. Of the following medications, which is most likely to be responsible for this presentation?

Answer 73

Amitriptyline This patient is suffering from anticholinergic syndrome. Amitriptyline, as a tricyclic antidepressant, carries a high anticholinergic burden and should be used with caution in elderly patients.

Question 74

A 30-year-old woman presents to her general practitioner having missed her doses of methadone for six consecutive days. She is currently experiencing cravings, lacrimation, rhinorrhoea, as well as mild nausea and vomiting. She has a 3-year history of heroin dependence. She has been receiving maintenance therapy with methadone for the past 3 months. She denies alcohol or any other substance use. Which is the most appropriate management of methadone prescription?

Answer 74

Reinduction of methadone If methadone doses are missed for 5 or more consecutive days, reassessment of the patient's current condition should take place, and reinduction is recommended. This is important to determine the suitable dose of methadone to minimise withdrawal symptoms and prevent overdose.

Question 75

A 50-year-old man presents to the Emergency Department with a 1-day history of confusion. He has known alcohol dependence and says his last drink was one day ago. His observations are as follows: Temperature 36.4 °C Heart rate 106 bpm Respiratory rate 16 breaths/min Blood pressure 110/76 mmHg SpO2 98% He appears cachectic. Neurological examination reveals ataxia and bilateral lateral recti palsy. His capillary blood glucose is 5.4 mmol/L (normal <6.1 mmol/L). What is the most likely diagnosis?

Answer 75

Wernicke's encephalopathy Wernicke's encephalopathy is an acute neurological condition due to thiamine/vitamin B1 deficiency. It is characterised by the triad of confusion, ataxia and ophthalmoplegia (weakness or paralysis of the eye muscles). Only 10% of patients present with all three symptoms; therefore, a high index of suspicion is required for patients at risk of Wernicke's encephalopathy. Thiamine deficiency leading to Wernicke's encephalopathy has a variety of causes, eg. prolonged starvation, anorexia nervosa, hyperemesis gravidarum, gastrointestinal diseases and malabsorption, other than chronic alcoholism.

Question 76

A 32-year-old man is brought by his wife to the emergency department due to 'unusual behaviour'. He believes his enemies are coming to attack him but is not worried as he has superpowers. He describes supportive friends who encourage him to fight against his enemies. His wife says he talks out loud when no one is around. In the past week, she says her husband has had an unusually joyful mood and high energy levels. He has no history of alcohol or substance misuse. His observations are: RR 18, oxygen saturations 98%, HR 110, BP 150/96, temperature 37.0°C. What is the most likely diagnosis?

Answer 76

Mania with psychotic symptoms This man has some signs and symptoms of mania – elated mood, high energy level and grandiose delusion as well as some signs of psychosis, such as auditory hallucinations. schizophrenia needs 1 month or more

Question 77

old lady on anticoags antidepressant

Answer 77

Mirtazapine Mirtazapine is a noradrenergic and specific serotonergic antidepressant (NaSSA). It is generally used as a second-line treatment of depression when a selective serotonin reuptake inhibitor (SSRI) is inappropriate or ineffective. An SSRI is associated with an increased risk of bleeding when prescribed with anticoagulants, especially among the elderly. An SSRI is normally avoided in this situation.

Question 78

A 15-year-old male presents for the first time to A&E after the loss of function of his right hand. He states his hand felt numb this morning and then he has lost movement throughout the day. He is very stressed, as he has his GCSE exams to sit and needs to do well to get into his apprenticeship. He undergoes a series of tests and examinations that can find no cause of the paralysis. What is the most likely cause of his symptoms?

Answer 78

conversion disorder

Question 79

sertraline most common side effects

Answer 79

The most common side effects are gastrointestinal disturbances (including gastric ulcers) and increased anxiety and agitation, especially in the first 2 weeks.

Question 80

A 24-year-old male attends his GP surgery feeling generally unwell. He is a regular user of heroin, but has recently run out of money and so has not taken any heroin for the last 24 hours. During the consultation he reports feeling extremely anxious, with watering eyes and a stomach ache. His most troubling symptom is the diarrhoea, which has occurred five times already since waking. Which of the following is the most appropriate first line management?

Answer 80

Loperamide In acute heroin withdrawal, NICE specifically advises against prescribing opiates and instead recommends symptomatic management. As this man's most troubling symptom is diarrhoea, loperamide is the most appropriate option. Alternatively lofexidine (an alpha 2 receptor agonist) can be used to help relieve physical symptoms, and benzodiazepines can be given for agitation.

Question 81

A 33-year-old nursery worker diagnosed with emotionally unstable personality disorder (EUPD) begins dialectical behaviour therapy to help self-regulate her emotions. Which of the following phenomena are most characteristic of emotionally unstable personality disorder?

Answer 81

Splitting is a phenomenon sometimes seen in EUPD, whereby relationships alternate between idealisation and devaluation. As a result, patients may regard others as either wholly good, or wholly bad, often without reasonable grounds to hold such opinions.

Question 82

alogia

Answer 82

The patient demonstrates alogia, or paucity of speech. This is a common negative symptom of schizophrenia.

Question 83

A 55-year-old teacher is brought to the GP surgery by her partner who is concerned about her memory. 3 days ago the partner found her attempting to enter a stranger's garden. When found, she did not know what she was doing and did not recognise him. However, within an hour, her confusion appeared to resolve, and she has not demonstrated any further episodes since. Prior to this, there was no history of confusion or memory loss, and the patient functions well at work. She has no conditions other than diet-controlled type 2 diabetes. Blood tests are normal. What is the most likely diagnosis?

Answer 83

Transient global amnesia Transient global amnesia is a neurological condition characterised by both short-term and long-term memory disruption. Episodes typically last a matter of hours before resolving, after which patients usually make a full recovery, as seen by this patient. delirium fluctuates over time