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  • Question 1 - A 42-year-old man states he has special powers that allow him to know...

    Correct

    • A 42-year-old man states he has special powers that allow him to know what other people are thinking. He also believes he is related to the Royal family. He has been overactive, elated in mood and not sleeping.
      Select from the list the term that best describes his delusions.

      Your Answer: Grandiose delusions

      Explanation:

      Understanding Delusions: Types and Associated Mental Illnesses

      Delusions are false beliefs that persist despite evidence to the contrary and are not accepted by others in the person’s culture or subculture. There are various types of delusions, each associated with different mental illnesses.

      Grandiose delusions are beliefs of exaggerated importance and are often seen in mania. Nihilistic delusions involve a persistent denial of the existence of things or everything, including oneself, and are common in schizophrenia. Delusions of guilt are found in depressive illnesses, while delusions of reference are seen in schizophrenia and mania.

      Persecutory delusions involve the belief that the person or someone close to them is being mistreated or spied on, and are common in schizophrenia, depression, and organic mental states. Understanding the different types of delusions and their associated mental illnesses can aid in diagnosis and treatment.

    • This question is part of the following fields:

      • Mental Health
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  • Question 2 - A 36-year-old man, with a history of alcohol addiction, visits a clinic after...

    Correct

    • A 36-year-old man, with a history of alcohol addiction, visits a clinic after a motorcycle accident two weeks ago. He experiences flashbacks of the accident and becomes hyper-vigilant to loud noises when he passes by the road. He has not ridden his motorcycle since the accident. His alcohol test at the time of the accident was negative.

      What is the most suitable initial treatment option?

      Your Answer: Trauma-focused cognitive-behavioural therapy (CBT)

      Explanation:

      Eye movement desensitization and reprocessing (EMDR)

      Acute stress disorder is a type of acute stress reaction that occurs within the first four weeks after a person has experienced a traumatic event, such as a life-threatening situation or sexual assault. This is different from post-traumatic stress disorder (PTSD), which is diagnosed after four weeks. Symptoms of acute stress disorder include intrusive thoughts, dissociation, negative mood, avoidance, and arousal. Intrusive thoughts may include flashbacks or nightmares, while dissociation may involve feeling like one is in a daze or experiencing time slowing down. Negative mood may manifest as feelings of sadness or hopelessness, while avoidance may involve avoiding places or people that remind one of the traumatic event. Arousal symptoms may include hypervigilance and sleep disturbance.

      The management of acute stress disorder typically involves trauma-focused cognitive-behavioral therapy (CBT) as a first-line treatment. Benzodiazepines may also be used to manage acute symptoms such as agitation or sleep disturbance, but caution should be exercised due to their addictive potential and concerns that they may be detrimental to adaptation. Overall, early intervention and treatment can help individuals with acute stress disorder recover and prevent the development of PTSD.

    • This question is part of the following fields:

      • Mental Health
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  • Question 3 - A 35-year-old male contacts his GP at 2PM to schedule his blood tests...

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    • A 35-year-old male contacts his GP at 2PM to schedule his blood tests following a recent visit to his psychiatrist. The psychiatrist has raised his dosage of lithium and requested that the GP arrange for lithium levels to be checked at the appropriate time after taking the medication. The patient took his first increased dose of lithium at 10AM (two hours ago).

      When should the GP schedule the blood test to be taken?

      Your Answer: 8 hours

      Explanation:

      Lithium is a medication used to stabilize mood in individuals with bipolar disorder and as an adjunct in refractory depression. It has a narrow therapeutic range of 0.4-1.0 mmol/L and is primarily excreted by the kidneys. The mechanism of action is not fully understood, but it is believed to interfere with inositol triphosphate or cAMP formation.

      Common adverse effects of lithium include nausea, vomiting, diarrhea, fine tremors, and nephrotoxicity. It may also cause thyroid enlargement, ECG changes, weight gain, idiopathic intracranial hypertension, leucocytosis, and hyperparathyroidism.

      Monitoring of patients on lithium therapy is crucial to prevent toxicity. It is recommended to check lithium levels 12 hours after the last dose and weekly after starting or changing the dose until concentrations are stable. Once established, lithium levels should be checked every 3 months. Thyroid and renal function should be checked every 6 months. Patients should be provided with an information booklet, alert card, and record book. Inadequate monitoring of patients taking lithium is common, and guidelines have been issued to address this issue.

    • This question is part of the following fields:

      • Mental Health
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  • Question 4 - A 55-year-old woman comes to you with a history of multiple recurrent and...

    Incorrect

    • A 55-year-old woman comes to you with a history of multiple recurrent and frequently changing symptoms that are 'functional' in nature (somatisation disorder).

      Which of the following statements regarding her management is accurate?

      Your Answer: Her progress will be slower if she thinks her doctors do not believe her

      Correct Answer: She should be persuaded to understand that her symptoms are psychological

      Explanation:

      Understanding Somatisation Disorder

      Somatisation disorder is a complex condition that has been frequently asked about in previous examinations. It is important to note that knowledge of early childhood experiences is not necessary for diagnosis. However, depression is often found in individuals with somatisation disorder, making antidepressants a useful treatment option. In addition, involving relatives in the management of the disorder can be beneficial. It is important to approach management with empathy rather than persuasion. Understanding the complexities of somatisation disorder is crucial for effective treatment and management.

      Spacing:

      Somatisation disorder is a complex condition that has been frequently asked about in previous examinations. It is important to note that knowledge of early childhood experiences is not necessary for diagnosis. However, depression is often found in individuals with somatisation disorder, making antidepressants a useful treatment option.

      In addition, involving relatives in the management of the disorder can be beneficial. It is important to approach management with empathy rather than persuasion. Understanding the complexities of somatisation disorder is crucial for effective treatment and management.

    • This question is part of the following fields:

      • Mental Health
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  • Question 5 - A 25-year-old woman's life has become increasingly difficult due to excessive washing in...

    Correct

    • A 25-year-old woman's life has become increasingly difficult due to excessive washing in an attempt to prevent contamination by faeces and urine. She is fortunate to have her own bathroom at home for her exclusive use and showers several times a day and repeatedly washes her hands. She is reluctant to venture far from home for fear of contamination and is especially afraid of using public toilets. She has become quite anxious and her sleep is disturbed.
      Select from the list below the single most suitable initial management option.

      Your Answer: Cognitive behaviour therapy

      Explanation:

      Management of Obsessive Compulsive Disorder (OCD)

      Obsessive Compulsive Disorder (OCD) is a mental health condition that requires proper management based on its severity. Cognitive behavioural therapy, including exposure and response prevention (ERP), is beneficial for all patients with OCD. This therapy involves exposure to triggers and preventing compulsive behaviours. The intensity and delivery of the intervention depend on the severity of the condition and can be individual or group-based. Selective serotonin re-uptake inhibitors (SSRIs) are recommended as an adjunct for patients who cannot engage in low-intensity psychological treatment or if such treatment has failed. Clomipramine is an alternative drug for patients with more severe symptoms. Although hypnotherapy and social skills therapy have been used in OCD patients, they are not included in the NICE guidelines.

      Managing Obsessive Compulsive Disorder (OCD) with Cognitive Behavioural Therapy and Medications

    • This question is part of the following fields:

      • Mental Health
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  • Question 6 - A 50-year-old woman has a history of bipolar disorder. She is brought by...

    Correct

    • A 50-year-old woman has a history of bipolar disorder. She is brought by her husband who is concerned that she is entering a manic phase.
      Select from the list the single feature that would NOT suggest a diagnosis of mania.

      Your Answer: Loss of interest in pleasurable activities

      Explanation:

      Understanding Mania and Hypomania in Bipolar Disorder

      Mania and hypomania are two terms used to describe the elevated mood states experienced by individuals with bipolar disorder. Mania is a more severe form of elevated mood, often accompanied by psychotic symptoms such as delusions and hallucinations. Hypomania, on the other hand, is a milder form of mania without psychotic symptoms.

      To diagnose mania, at least three of the following symptoms must be present: inflated self-esteem, decreased need for sleep, rapid and emphatic speech, flight of ideas, distractibility, psychomotor agitation, and excessive involvement in pleasurable activities without regard for consequences.

      It’s important to note that nearly all cases of mania will eventually lead to episodes of depression, which is why bipolar disorder is often grouped with mania. Understanding the symptoms of mania and hypomania can help individuals with bipolar disorder and their loved ones recognize when they may need to seek professional help.

    • This question is part of the following fields:

      • Mental Health
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  • Question 7 - John is a 55-year-old man who is admitted to an inpatient psychiatric hospital...

    Correct

    • John is a 55-year-old man who is admitted to an inpatient psychiatric hospital under section 3. He has refused to eat or drink as he believes he is already dead and no longer needs sustenance. What is the name of the syndrome where a person thinks they are non-existent or deceased?

      Your Answer: Cotard syndrome

      Explanation:

      Cotard syndrome is a condition where individuals believe that they are dead or do not exist, often associated with depression. Capgras syndrome, on the other hand, is a condition where individuals believe that their loved ones have been replaced by identical imposters. Couvade syndrome, also known as sympathetic pregnancy, affects fathers who experience physical symptoms similar to those of their pregnant partners. Finally, De Clerambault’s syndrome is a condition where individuals believe that a celebrity or another person is deeply in love with them, typically affecting females.

      Understanding Cotard Syndrome

      Cotard syndrome is a mental illness that is characterized by the belief that one is either dead or doesn’t exist. This rare disorder is often associated with severe depression and psychotic disorders. Patients with Cotard syndrome may stop eating or drinking as they believe it is not necessary. This delusion can be challenging to treat and can result in significant problems for the patient.

    • This question is part of the following fields:

      • Mental Health
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  • Question 8 - A 30-year-old man with schizophrenia has recently started taking clozapine after struggling to...

    Correct

    • A 30-year-old man with schizophrenia has recently started taking clozapine after struggling to find an effective Antipsychotic treatment. His full blood count results are as follows:
      Hb 152 g/l
      MCV 87 fL
      WBC 2.0 x 109/L
      Neutrophils 0.9 x 109/L
      Lymphocytes 1.0 x 109/L
      Platelets 322 x 109/L
      What is the most suitable action to take in this case?

      Your Answer: Stop Clozapine

      Explanation:

      Agranulocytosis and Neutropenia in Clozapine Treatment

      Clozapine is a medication used to treat schizophrenia. However, it carries a risk of agranulocytosis and neutropenia, which are conditions that affect the white blood cells. Agranulocytosis occurs in approximately 1% of patients taking clozapine, while neutropenia occurs in about 3%. The highest risk of developing these conditions is between 6 and 18 weeks after starting clozapine treatment.

      Before starting clozapine treatment, blood counts must be normal. During the first 18 weeks of treatment, a full blood count is required weekly. Afterward, the frequency can be reduced to every 2 or 4 weeks after 12 months. If the leucocyte count falls below 3000/mm or the absolute neutrophil count falls below 1500/mm, the medication should be stopped, and the patient should be referred to a haematologist.

      Patients taking clozapine should report any symptoms of infection immediately. However, an exception is made for patients with benign ethnic neutropenia. If a haematologist approves, they may be started on the medication. It is essential to monitor blood counts regularly to prevent the development of agranulocytosis and neutropenia.

    • This question is part of the following fields:

      • Mental Health
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  • Question 9 - A 25-year-old teacher has come to see you because she has been feeling...

    Incorrect

    • A 25-year-old teacher has come to see you because she has been feeling down for the past four weeks. She recently ended a long-term relationship and is struggling with the demands of her job. She shares that she still lives with her parents due to financial constraints and that she frequently argues with them and her younger sister. She expresses interest in taking non-addictive medication to improve her mood and seeing a psychotherapist to work through her issues. You administer a PHQ assessment questionnaire and calculate her score. According to the PHQ assessment, what is the recommended threshold score that indicates the need for active treatment with psychotherapy, medication, or a combination of both?

      Your Answer: Score 15

      Correct Answer: Score 9

      Explanation:

      Recommended Questionnaires for Primary Care

      The use of validated questionnaires in primary care can aid clinicians in assessing the severity of depression and guiding management. Three recommended questionnaires are PHQ-9, HADS, and BDI-II. It is important to familiarize oneself with the basic principles of each questionnaire in case of examination.

      The PHQ-9 assessment is particularly useful in determining the severity of depression and the need for intervention. The maximum score is 27, with a score of 15 being the threshold for considering intervention. The higher the score, the greater the symptoms.

      Based on the limited information provided in the patient’s history, it is unlikely that antidepressant treatment and psychotherapy referral would be necessary. However, the use of these questionnaires can provide a more comprehensive assessment and aid in the management of depression in primary care.

    • This question is part of the following fields:

      • Mental Health
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  • Question 10 - A 56-year-old man with longstanding bipolar disorder has recently joined your practice after...

    Incorrect

    • A 56-year-old man with longstanding bipolar disorder has recently joined your practice after moving to the area. He has been on a stable dosage of lithium for the past 4 years and has been adherent to treatment. He has no other medical history of note and is not taking any medication that interacts with lithium. His previous blood tests have all been within normal limits, with a serum lithium level consistently around 0.5 mmol/litre (within target range).

      What is the minimum ongoing blood monitoring required for this patient in relation to his lithium treatment?

      Your Answer: Serum lithium level, full blood count and thyroid function every 6 months

      Correct Answer: Serum lithium level, serum electrolytes, eGFR, thyroid function and full blood count annually

      Explanation:

      Lithium Monitoring Requirements

      Lithium is a medication with a narrow therapeutic ratio, which means it requires careful monitoring. The British National Formulary (BNF) outlines the monitoring requirements for patients taking lithium. After initiation and each dose change, serum-lithium monitoring should be carried out weekly until concentrations are stable. After that, it should be checked every 3 months for the first year and every 6 months thereafter as a minimum.

      Patients who are 65 years and above, taking drugs that may interact with lithium, at risk of impaired renal or thyroid function, have high calcium levels, poor symptom control or adherence to treatment, or whose last serum-lithium concentration was 0.8 mmol/litre or higher should be monitored every 3 months. Additionally, serum-lithium measurements should be checked if there is a significant intercurrent illness/disease or a significant change in sodium or fluid intake.

      Before treatment is initiated, renal, cardiac, and thyroid function should be assessed, and an ECG is recommended for those with cardiovascular disease or risk factors. Body-weight/BMI, serum electrolytes, and a full blood count should also be measured. During treatment, body-weight/BMI, serum electrolytes, eGFR, and thyroid function should be monitored every 6 months. If there is evidence of impaired renal or thyroid function or raised calcium levels, monitoring should be more frequent.

    • This question is part of the following fields:

      • Mental Health
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  • Question 11 - A woman in her 50s comes to you with symptoms of moderate depression....

    Incorrect

    • A woman in her 50s comes to you with symptoms of moderate depression. She has experienced severe side effects from SSRIs and you are considering prescribing a tricyclic antidepressant instead. Before doing so, you review her medical history for any potential contraindications to taking tricyclics.

      Which of the following conditions could be a contraindication to using tricyclic antidepressants?

      Your Answer: Cardiac disease

      Correct Answer: Migraine

      Explanation:

      Tricyclic Antidepressants and Heart Issues

      Tricyclic antidepressants, specifically amitriptyline, may cause arrhythmias and heart block. These issues can occur occasionally and should be avoided if there is a high risk of arrhythmia. It is important to be aware of the potential heart-related side effects when considering tricyclic antidepressants as a treatment option. If there is a history of heart problems or a high risk of arrhythmia, alternative medications should be considered. It is always important to discuss any concerns or questions with a healthcare provider before starting any new medication.

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      • Mental Health
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  • Question 12 - A 58-year-old woman is brought to the doctors by her son. Three weeks...

    Correct

    • A 58-year-old woman is brought to the doctors by her son. Three weeks ago her husband died from pancreatic cancer. She reports being tearful every day but her son is concerned because she is constantly 'picking fights' with him over minor matters and issues relating to their family past. The son also reports that she has on occasion described hearing her husband talking to her and on one occasion she set a place for him at the dinner table.

      Despite this she has started going to yoga classes again with friends and says that she is determined to get 'back on track'.

      What is the most likely diagnosis?

      Your Answer: Normal grief reaction

      Explanation:

      Understanding Grief Reactions

      Grief is a natural response to the loss of a loved one, but it can be helpful to have an understanding of the potential stages a person may go through while grieving. One popular model divides grief into five stages: denial, anger, bargaining, depression, and acceptance. However, not everyone will experience all five stages.

      Abnormal or atypical grief reactions are more likely to occur in women and when the death is sudden or unexpected. Other risk factors include a problematic relationship before death or a lack of social support. Delayed grief, which occurs when grieving doesn’t begin for more than two weeks, and prolonged grief, which can last beyond 12 months, are features of atypical grief reactions.

      It is important to note that grief doesn’t necessarily need to be medicalized, but understanding the potential stages and risk factors can help determine if a patient is experiencing a normal grief reaction or if they may need additional support.

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      • Mental Health
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  • Question 13 - An anxious mother brings her 15-year-old daughter to see you as she is...

    Correct

    • An anxious mother brings her 15-year-old daughter to see you as she is worried that she may be depressed or using drugs, although she has no evidence of the latter. She had previously been happy and healthy and performing well at school, but recently has become withdrawn, has started failing at school and is often heard shouting in her bedroom, which she locks herself into most of the day. She has accused her parents of trying to harm her when they have encouraged her to come out.
      Select from the list the most likely diagnosis.

      Your Answer: Acute schizophrenia

      Explanation:

      Early Intervention for Acute Schizophrenia and Substance Use

      This patient is exhibiting symptoms of acute schizophrenia, including social withdrawal, declining academic performance, delusions of persecution, and hallucinations. Substance use is a common factor in the development of psychosis, with cocaine, amphetamines, cannabis, and alcohol use linked to a higher risk of developing schizophrenia. Research suggests that cannabis use, in particular, may contribute to the development of schizophrenia. However, signs of drug use typically precede the onset of thought disorders. To ensure the best possible outcome, this patient should be referred to an early intervention team for prompt diagnosis and treatment. Early intervention is crucial for managing acute schizophrenia and substance use disorders.

    • This question is part of the following fields:

      • Mental Health
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  • Question 14 - A 26-year-old man is brought in by his sister who is very upset...

    Incorrect

    • A 26-year-old man is brought in by his sister who is very upset as she found him this morning acting strangely. Looking at his record he has a history of depression and substance misuse.

      When you see him he is very paranoid at having been brought to the doctor's surgery and says that you are 'working for them'. He can see 'little men with guns lying on the floor trying to shoot him' and tells you that he is wanted by the government because he works as a secret spy.

      He is somewhat agitated and whilst trying to talk to him he is obviously distracted and displays pressure of speech. Which of the symptoms displayed by this patient most strongly suggests that the psychosis is related to substance misuse rather than a schizophrenic illness?

      Your Answer: Visual hallucinations

      Correct Answer: Paranoia

      Explanation:

      Discriminating between Psychosis due to Drug Abuse and Schizophrenic Illness

      Visual hallucinations are a common symptom in organic brain disorders and drug and alcohol intoxication and withdrawal. They are often associated with diagnoses such as stimulant/hallucinogen abuse, delirium tremens, dementia, and certain brain tumors. On the other hand, auditory hallucinations are more commonly seen in functional psychoses, particularly in schizophrenia. The first-rank symptoms of schizophrenia include auditory hallucinations in the form of third person, running commentary, and thought echo. By identifying these specific features, it is possible to discriminate between psychosis due to drug abuse and psychosis due to a schizophrenic illness.

    • This question is part of the following fields:

      • Mental Health
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  • Question 15 - A 65-year-old woman presents due to a 6-month history of cognitive decline. On...

    Correct

    • A 65-year-old woman presents due to a 6-month history of cognitive decline. On examination, the General Practitioner notices she has a resting tremor and shuffling gait.
      What is the most likely diagnosis?

      Your Answer: Lewy body dementia

      Explanation:

      Differentiating Lewy Body Dementia from Other Dementia-Related Disorders

      Lewy body dementia (LBD) is a type of dementia that is often misdiagnosed due to its similarity to other dementia-related disorders. One key feature that sets LBD apart is the presence of Parkinsonian symptoms, such as tremors and rigidity. In fact, LBD is diagnosed when a patient develops symptoms of dementia either before or at the same time as Parkinsonian symptoms. Other characteristic features of LBD include fluctuations in cognition and alertness, visual hallucinations, hypersensitivity to neuroleptic medication, and repeated falls.

      It is important to differentiate LBD from other disorders, such as Alzheimer’s disease, Creutzfeldt-Jakob disease, frontotemporal dementia, and Huntington’s disease. Alzheimer’s disease would not give you Parkinsonian symptoms, while Creutzfeldt-Jakob disease is a rapidly progressing physical and cognitive decline that doesn’t feature Parkinsonian symptoms. Frontotemporal dementia would not give you Parkinsonian symptoms either, and typically presents with prominent changes in personality and social behavior. Huntington’s disease initially presents with chorea, personality changes, and neuropsychiatric symptoms, followed later by dementia, but doesn’t feature Parkinsonian symptoms. By understanding the unique features of LBD and how it differs from other disorders, healthcare professionals can provide more accurate diagnoses and appropriate treatment plans for their patients.

    • This question is part of the following fields:

      • Mental Health
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  • Question 16 - A 32-year-old teacher comes to see you because she feels depressed.

    She was recently...

    Incorrect

    • A 32-year-old teacher comes to see you because she feels depressed.

      She was recently given a new class to teach and feels overwhelmed. She believes that her colleagues think she is not capable of handling the class and that her teaching is not up to par. She has started to wake up in the early hours and then worry about her job.

      Her reason for coming to the clinic is that she has been feeling irritable and short-tempered with her students, and her partner thinks she should seek help. She doesn't smoke or drink alcohol.

      How would you evaluate her symptoms of depression?

      Your Answer: A PHQ-9 questionnaire

      Correct Answer: An IPSS symptom score

      Explanation:

      Popular Questionnaires in General Practice

      Questionnaires are commonly used in general practice to detect and assess the severity of illnesses. One such questionnaire is the PHQ-9, which is a nine-item depression scale that assists general practitioners in diagnosing depression and monitoring treatment. The PHQ-2, a two-item questionnaire, is also used for screening depression.

      The CAGE questionnaire, on the other hand, is a screening test for alcohol problem drinking and is not used to assess depression. The GPCOG assessment is a screening tool for symptoms of dementia, while the GPPAQ questionnaire is a validated short measure of physical activity commissioned by the Department of Health.

      It is important to note that the IPSS questionnaire, which is an international prostate symptom score questionnaire, is not relevant to the assessment of depression. Overall, these questionnaires serve as powerful tools for general practitioners in diagnosing and monitoring various illnesses.

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      • Mental Health
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  • Question 17 - A 65-year-old man has just been released from the hospital following a heart...

    Incorrect

    • A 65-year-old man has just been released from the hospital following a heart attack. He has a history of depression and is currently experiencing low mood. What is the antidepressant with the most safety evidence for patients with recent unstable angina or myocardial infarction?

      Your Answer: Sertraline

      Correct Answer: Citalopram

      Explanation:

      Sertraline as the Treatment of Choice for CHD Patients

      NICE guidance recommends sertraline as the treatment of choice for patients with coronary heart disease (CHD) due to its safety and efficacy. Sertraline has been found to be cost-effective in a study conducted by O’Connor and colleagues in a hospitalised population with acute coronary syndrome. Although limited to one study, this evidence supports the use of sertraline in this population. Additionally, the SPS recommends sertraline as the selective serotonin reuptake inhibitor (SSRI) of choice for CHD patients due to its lower propensity for interactions and the availability of more data on its use in a population with pre-existing heart disease compared to other SSRIs. Overall, sertraline is a safe and effective treatment option for CHD patients with depression or anxiety.

    • This question is part of the following fields:

      • Mental Health
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  • Question 18 - A 30-year-old man is brought to his psychiatrist by his sister. She is...

    Correct

    • A 30-year-old man is brought to his psychiatrist by his sister. She is worried that her brother firmly believes that he is a superhero with special powers, despite no evidence to support this claim.

      During the assessment, the man appears physically healthy and there are no signs of disordered speech or confusion. However, he maintains an unwavering belief in his superhero abilities.

      What is the appropriate diagnosis for this condition?

      Your Answer: De Clerambault's syndrome

      Explanation:

      De Clerambault’s syndrome, also known as Erotomania, is characterized by a delusion that a famous person is in love with the individual, without any other accompanying psychotic symptoms.

      De Clerambault’s Syndrome: A Delusional Belief in Famous Love

      De Clerambault’s syndrome, also referred to as erotomania, is a type of paranoid delusion that has a romantic aspect. This condition is commonly observed in single women who believe that a well-known individual is in love with them. In simpler terms, the patient has a false belief that a celebrity or public figure is romantically interested in them. This delusion can be so intense that the patient may even stalk or harass the object of their affection. De Clerambault’s syndrome is a rare condition that requires professional medical attention to manage.

    • This question is part of the following fields:

      • Mental Health
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  • Question 19 - During an out of hours shift, you are called to see an 80-year-old...

    Correct

    • During an out of hours shift, you are called to see an 80-year-old man who has developed acute urinary retention on a background of 2 years of urinary hesitancy and poor stream. He has a history of ischaemic heart disease, hypertension and he tells you that his usual GP has recently started him on a new medication for neuropathic pain.

      Which of the following drugs is most likely to have caused the urinary retention?

      Your Answer: Amitriptyline

      Explanation:

      Urinary retention may be caused by tricyclic antidepressants, particularly Amitriptyline, due to its anticholinergic effects. This can result in symptoms such as tachycardia, dry mouth, mydriasis, and urinary retention. However, SSRIs like fluoxetine and SNRIs like venlafaxine are not typically associated with these side effects, with dry mouth and urinary retention being rare occurrences. Unlike Amitriptyline, Diazepam, a benzodiazepine, doesn’t have anticholinergic effects.

      Tricyclic antidepressants (TCAs) are not commonly used for depression anymore due to their side-effects and potential for toxicity in overdose. However, they are still widely used for the treatment of neuropathic pain, where smaller doses are typically required. The common side-effects of TCAs include drowsiness, dry mouth, blurred vision, constipation, urinary retention, and lengthening of QT interval. When choosing a TCA, low-dose amitriptyline is commonly used for the management of neuropathic pain and the prevention of headaches. Lofepramine is preferred due to its lower incidence of toxicity in overdose, while amitriptyline and dosulepin are considered the most dangerous in overdose. The sedative effects of TCAs vary, with amitriptyline, clomipramine, dosulepin, and trazodone being more sedative, while imipramine and nortriptyline are less sedative. Trazodone is technically a ‘tricyclic-related antidepressant’.

    • This question is part of the following fields:

      • Mental Health
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  • Question 20 - A 70-year-old woman is brought to the General Practitioner by her carer. She...

    Correct

    • A 70-year-old woman is brought to the General Practitioner by her carer. She lives in sheltered accommodation and has carers twice a day to help with washing, dressing and meal preparation. Typically, she enjoys crosswords and is able to mobilise around the house with the help of a walking stick. Over the past two days, she has become restless and agitated. When the carer arrived that morning, she had been very combative and refused to get dressed.
      Given the likely diagnosis, what is the most appropriate intervention?

      Your Answer: Arrange admission to hospital for assessment, monitoring and treatment

      Explanation:

      Managing Delirium in Hospitalized Patients

      When a patient presents with delirium, it is important to take immediate action to ensure their safety and well-being. Admission to the hospital for assessment, monitoring, and treatment is typically necessary. The decision to admit should take into account the patient’s clinical and social situation, as well as the input of family members or caregivers. If the patient lacks capacity, decisions should be made in their best interests using the Mental Capacity Act 2005.

      Once the patient has recovered from delirium, it is important to review them to ensure there are no underlying memory concerns that would warrant a referral to the Memory Clinic. Physical restraints, such as cot sides, should be avoided in patients with delirium. Instead, strategies to maintain safe mobility should be employed, such as encouraging walking or active range of motion exercises.

      A computed tomography head may be indicated if there has been a recent head injury or a subdural hematoma is suspected, or if the patient may have underlying dementia. However, if an acute cause is suspected, the patient needs admission to the hospital. If dementia is suspected, then referral to the Memory Clinic once the patient has recovered from delirium is recommended.

      Pharmacological measures are a last resort for severe agitation or psychosis that may be recommended by specialists. Short-term, low-dose haloperidol may be suggested, but benzodiazepines are not usually recommended. By following these guidelines, healthcare professionals can effectively manage delirium in hospitalized patients.

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      • Mental Health
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  • Question 21 - A 60-year-old woman with a 25-year history of treatment with antipsychotic medications for...

    Correct

    • A 60-year-old woman with a 25-year history of treatment with antipsychotic medications for schizophrenia complains of the onset of writhing tongue and finger movements.
      Select from the list the single most likely cause.

      Your Answer: Tardive dyskinesia

      Explanation:

      Understanding Tardive Dyskinesia and Differential Diagnosis

      Tardive dyskinesia is a condition that can develop in patients who have been on long-term treatment with antipsychotic medications. It is characterized by choreoathetoid movements that typically start in the fingers and tongue before becoming more widespread. While Huntington’s disease and Wilson’s disease can also present with tremors and choreiform movements, they usually have an earlier onset than tardive dyskinesia. Parkinsonism, on the other hand, is characterized by resting tremors and bradykinesia, while akathisia is characterized by motor restlessness. It is important to note that antipsychotic medications can also cause Parkinson’s symptoms and akathisia. Therefore, a thorough differential diagnosis is necessary to accurately diagnose and treat tardive dyskinesia.

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      • Mental Health
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  • Question 22 - A 25-year-old cleaner is brought in to see you by her mother and...

    Incorrect

    • A 25-year-old cleaner is brought in to see you by her mother and husband because they are worried that she may commit suicide.

      In recent months, the couple have lost their home due to debt and are living back home with her parents and her two young sons (aged 4 and 2). She has never attempted suicide before but has expressed fleeting suicidal thoughts, having been depressed for weeks about their current circumstances.

      Which one of the following features from this history is a risk factor for suicide?

      Your Answer: Age <30

      Correct Answer:

      Explanation:

      Suicide Risk Factors in Depressed Patients

      When managing depressed patients, clinicians should always ask about suicidal intent. It is important to have knowledge of risk factors for suicide during the assessment process. Protective factors include good family support and responsibility for children. However, there are several risk factors that increase the likelihood of suicidal thoughts and behaviors. These include being male, under 30 years old or advancing in age, single, living alone, having a history of substance abuse, and experiencing feelings of hopelessness. By understanding these risk factors, clinicians can better assess and manage the care of depressed patients who may be at risk for suicide.

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      • Mental Health
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  • Question 23 - An 82-year-old woman is brought to the General Practitioner by her son because...

    Correct

    • An 82-year-old woman is brought to the General Practitioner by her son because of concerns about worsening confusion over the last two days. Her son has been staying with her as he is worried about her, and throughout the night, the patient was shouting out that she was seeing figures behind the curtains.
      Which of the following features most suggests a diagnosis of delirium?

      Your Answer: Symptoms developing rapidly over a few hours or days

      Explanation:

      Differentiating between Delirium and Dementia: Symptoms and Signs to Look Out For

      Delirium and dementia are two conditions that can cause confusion, memory problems, and other cognitive impairments. However, there are some key differences in how these conditions present themselves. Here are some symptoms and signs to look out for when trying to differentiate between delirium and dementia:

      Symptoms developing rapidly over a few hours or days: This is more consistent with delirium, which can cause confusion, hallucinations, and delusions to develop rapidly over a short period of time. Dementia, on the other hand, usually develops gradually over several months.

      Gradual worsening of symptoms over months: If symptoms such as confusion, poor concentration, and memory problems have been getting worse over a period of months, this is more suggestive of dementia.

      Improved mobility: Patients with delirium may suddenly have difficulty with tasks they could previously do easily, such as walking.

      Low mood: A low mood is more suggestive of depression, which usually develops over several weeks or months. However, hypoactive delirium can be misdiagnosed as depression, so it’s important to consider this possibility in patients who become suddenly withdrawn, drowsy, and unable to stay focused when awake.

      Patient’s ability to concentrate on reading her book club novel: Attention is usually reduced in delirium, but in the early stages of dementia, patients may still be able to concentrate on activities such as reading or watching television.

      By paying attention to these symptoms and signs, healthcare professionals can better differentiate between delirium and dementia and provide appropriate treatment.

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      • Mental Health
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  • Question 24 - What could be the probable reason for visual hallucinations in an 85-year-old woman...

    Correct

    • What could be the probable reason for visual hallucinations in an 85-year-old woman named Edith who sees frightening faces on the walls and insects on the floor, despite being aware that they are not real? She has a medical history of hypertension, depression, hearing loss, and macular degeneration.

      Your Answer: Charles Bonnet syndrome

      Explanation:

      Charles Bonnet syndrome can lead to distressing visual hallucinations in approximately one-third of those affected. While Lewy body dementia may also cause visual hallucinations and cognitive impairment, it is less likely in the absence of other neuropsychiatric symptoms. Acute psychosis typically involves auditory hallucinations and delusions, while psychotic depression is characterized by severe depression and the emergence of psychotic symptoms.

      Understanding Charles-Bonnet Syndrome

      Charles-Bonnet syndrome (CBS) is a condition characterized by complex hallucinations, usually visual or auditory, that occur in clear consciousness. These hallucinations persist or recur and are often experienced against a background of visual impairment, although this is not always the case. People with CBS typically retain their insight and do not experience any other significant neuropsychiatric disturbances.

      Several factors can increase the risk of developing CBS, including advanced age, peripheral visual impairment, social isolation, sensory deprivation, and early cognitive impairment. The condition affects both sexes equally and doesn’t appear to have any familial predisposition. Age-related macular degeneration is the most common ophthalmological condition associated with CBS, followed by glaucoma and cataract.

      Complex visual hallucinations are relatively common in people with severe visual impairment, occurring in 10-30% of cases. The prevalence of CBS in visually impaired individuals is estimated to be between 11 and 15%. Although some people find the hallucinations unpleasant or disturbing, CBS is typically a long-term condition, with 88% of people experiencing it for two years or more. Only 25% of people experience a resolution of their symptoms after nine years.

      In summary, CBS is a condition that can cause complex hallucinations in people with visual impairment. Although the hallucinations can be distressing, most people with CBS retain their insight and do not experience any other significant neuropsychiatric disturbances. The condition is relatively common in visually impaired individuals and tends to be a long-term condition.

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      • Mental Health
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  • Question 25 - A 21-year-old woman is brought to the General Practitioner by her parents. They...

    Correct

    • A 21-year-old woman is brought to the General Practitioner by her parents. They are concerned about uncharacteristic behaviour since she left home to attend university. They ask whether she could have developed schizophrenia.
      Which of the following symptoms in this patient would be most concerning for schizophrenia?

      Your Answer: Delusional perception

      Explanation:

      Understanding Schneider’s First-Rank Symptoms in Schizophrenia

      Schneider’s first-rank symptoms are a set of symptoms that are highly indicative of schizophrenia. These symptoms are rare in other psychotic illnesses, making them a key diagnostic tool for identifying schizophrenia. The first-rank symptoms include auditory hallucinations, such as hearing one’s own thoughts echoed or hearing voices referring to oneself in the third person. Other symptoms include thought removal, insertion, and interruption, thought broadcasting, somatic hallucinations, delusional perception, and feelings, thoughts, or actions being under external control.

      In addition to the first-rank symptoms, there are also second-rank symptoms that can be present in schizophrenia. These include other disorders of perception, sudden delusional ideas, perplexity, low or euphoric mood changes, and feelings of emotional impoverishment. Schneider believed that even in the absence of first-rank symptoms, a diagnosis of schizophrenia could be made based on second-rank symptoms and a typical clinical appearance.

      One unique symptom of schizophrenia is delusional perception, which occurs in two stages. First, the individual experiences a normal perception, such as seeing traffic lights turn red. Then, they interpret this perception in a delusional way, such as believing that the red traffic lights are a sign that they are the devil and someone is trying to kill them.

      It’s important to note that cognitive impairment is a feature of dementia, not schizophrenia. Additionally, hyperactivity is more commonly associated with mania than schizophrenia. Understanding the specific symptoms of schizophrenia, particularly the first-rank symptoms, can aid in accurate diagnosis and treatment.

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      • Mental Health
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  • Question 26 - What feature is typical of early-stage Alzheimer's disease? ...

    Incorrect

    • What feature is typical of early-stage Alzheimer's disease?

      Your Answer: Impaired short term memory

      Correct Answer: Myoclonic jerks

      Explanation:

      Differentiating Alzheimer’s Disease from Other Dementias

      Alzheimer’s disease is typically identified by the early onset of short term memory loss. However, other dementias may present with different symptoms that can help differentiate them from Alzheimer’s. For example, gait ataxia and urinary incontinence may suggest normal pressure hydrocephalus, while myoclonic jerks may indicate Creutzfeldt-Jakob disease. Visual hallucinations may be a sign of delirium or Lewy body dementia. It is important for healthcare professionals to consider these alternative diagnoses when evaluating patients with dementia symptoms. By identifying the specific type of dementia, appropriate treatment and management strategies can be implemented to improve patient outcomes.

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      • Mental Health
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  • Question 27 - You are taking a history from a 21-year-old man. He reports difficulty sleeping...

    Correct

    • You are taking a history from a 21-year-old man. He reports difficulty sleeping at night due to concerns about abusing his special powers. He claims to be able to read other people's thoughts and sometimes feels he can control their hand movements. He believes this to be true because a passage in the Bible can be translated with a special code that dictates his powers. Additionally, he reports hearing voices talking about him.
      What is the SINGLE CORRECT terminology for this type of delusion?

      Your Answer: Delusion of reference

      Explanation:

      Understanding Delusions: False Beliefs and Their Types

      Delusions are false beliefs that individuals hold onto despite evidence to the contrary. These beliefs are often maintained by altering other beliefs to keep their entire belief system consistent. There are several types of delusions, including delusions of reference, control, paranoia, replacement, and guilt.

      Delusions of reference involve the belief that something innocent in the public domain holds a special meaning for the individual. Delusions of control consist of the belief that an external force is controlling the patient, often citing electricity or radio waves as the mediator. Paranoid delusions involve the belief that people or organizations are plotting to harm or harass the patient, while delusions of replacement occur when someone in the patient’s life has been replaced by an impostor. Delusions of guilt involve feeling guilty or remorseful for no valid reason.

      Understanding the different types of delusions can help individuals recognize when someone they know may be experiencing them. It is important to seek professional help if someone is experiencing delusions, as they can be a symptom of a larger mental health issue.

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      • Mental Health
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  • Question 28 - A 35-year-old lady comes back to the clinic after four weeks of starting...

    Incorrect

    • A 35-year-old lady comes back to the clinic after four weeks of starting fluoxetine treatment for moderate depressive symptoms. She has no prior history of taking antidepressants and has no other medical conditions. During the assessment, she denies any suicidal thoughts and has good support from her partner at home. Despite taking fluoxetine regularly, she has not noticed any improvement in her symptoms and is considering switching to a different medication. She reports no adverse effects from fluoxetine but has heard positive feedback about St John's Wort from a friend. What would be the most appropriate action to take for this patient?

      Your Answer: Increase the dose of Fluoxetine and arrange weekly telephone contact to increase support

      Correct Answer: Change to a tricyclic antidepressant

      Explanation:

      Treatment Options for Patients with Minimal Response to SSRIs

      When a patient has been taking a Selective serotonin reuptake inhibitor (SSRI) for four weeks without benefit, it is important to consider alternative treatment options. Continuing at the current dose is not a satisfactory plan.

      There are essentially two options in addition to increasing the level of support: increasing the dose of the current antidepressant or changing to an alternative agent if there are side effects or the patient prefers. However, it is important to note that switching from fluoxetine to tricyclics requires great caution as it inhibits the metabolism. Therefore, a lower than usual starting dose of tricyclic would be required.

      Although there is some evidence of the benefit of St John’s Wort, it is not recommended that doctors prescribe or advocate its use due to the lack of clarity regarding doses, duration of effect, and variation in the nature of preparations. Additionally, there are serious drug interactions, particularly with oral contraceptives and antiepileptics.

      For moderate depression, Cognitive Behavioral Therapy (CBT) is recommended in addition to medication. It is important to monitor the patient’s response to treatment and adjust accordingly to ensure the best possible outcome.

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      • Mental Health
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  • Question 29 - Which one of the following statements regarding bulimia nervosa is accurate? ...

    Correct

    • Which one of the following statements regarding bulimia nervosa is accurate?

      Your Answer: It is the most common cause of admissions to child and adolescent psychiatric wards

      Explanation:

      Anorexia nervosa is a prevalent mental health condition that primarily affects teenage and young-adult females. It is the most common reason for admissions to child and adolescent psychiatric wards. The disorder is characterized by a restriction of energy intake, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health. Patients with anorexia nervosa also experience an intense fear of gaining weight or becoming fat, even though they are underweight. They may also have a distorted perception of their body weight or shape, which can affect their self-evaluation.

      The diagnosis of anorexia nervosa is based on the DSM 5 criteria, which no longer specifically mention BMI and amenorrhoea. Instead, the criteria focus on the restriction of energy intake, fear of gaining weight, and disturbance in the way one’s body weight or shape is experienced.

      The management of anorexia nervosa varies depending on the age of the patient. For adults, NICE recommends individual eating-disorder-focused cognitive behavioural therapy (CBT-ED), Maudsley Anorexia Nervosa Treatment for Adults (MANTRA), or specialist supportive clinical management (SSCM). In children and young people, NICE recommends ‘anorexia focused family therapy’ as the first-line treatment, followed by cognitive behavioural therapy as the second-line treatment.

      Unfortunately, the prognosis for patients with anorexia nervosa remains poor, with up to 10% of patients eventually dying because of the disorder.

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      • Mental Health
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  • Question 30 - A 32-year-old man is brought by his wife and appears to be experiencing...

    Correct

    • A 32-year-old man is brought by his wife and appears to be experiencing an elevated mood, along with increased activity and energy, and difficulty sleeping. He is extremely talkative and jumps quickly from one topic to another. He has no hallucinations or delusions. His wife believes he requires medication to help calm him down.

      What medication would be the most appropriate for the mental health team to prescribe for this patient?

      Your Answer: Olanzapine

      Explanation:

      Treatment for Mania/Hypomania

      Mania/hypomania is a condition that requires specialist mental health assessment. The patient may be prescribed atypical antipsychotic drugs such as olanzapine, quetiapine, or risperidone, which have a quicker onset and lower incidence of extrapyramidal side-effects compared to older antipsychotics like chlorpromazine. Alternatively, benzodiazepines like lorazepam may be used to aid sleep.

      Lithium, a mood stabilizer, has a slower onset of action and is only used alone if symptoms are mild. It is usually initiated after a specialist assessment. In this case, the treatment with antipsychotics is to calm the patient down in the immediate short-term. Managing mania or hypomania in adults requires careful consideration of the patient’s symptoms and individual needs.

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SESSION STATS - PERFORMANCE PER SPECIALTY

Mental Health (20/30) 67%
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