Day 5 Flashcards
A 64 year old man has been an inpatient in a psychiatric inpatient unit for three months with severe depression.
He has a six month history of low mood, which has been getting gradually worse.
He feels suicidal every day, although currently has no active plans to end his life.
He only sleeps for two hours a night and feels exhausted all of the time.
His appetite is so poor that he has gradually reduced his oral intake over the last few weeks and for the last two days he has not eaten or drunk anything except a few glasses of orange juice.
He has no motivation to get better and wants to be discharged so that he can die.
He has tried the antidepressants Sertraline, Fluoxetine and Venlafaxine with no improvement in his mood.
What is the next most appropriate step in the management of his depression?
Electroconvulsive therapy
Electroconvulsive therapy is indicated in this man, whose depression is resistant to usual antidepressant therapy and, given his reduced oral intake, has now become life threatening.
When a depressive episode becomes severe or life-threatening and requires a rapid response, a course of electroconvulsive therapy can offer an effective response.
A 57-year-old man is seen in dementia clinic.
His carer reports that his memory has been deteriorating and is concerned because of personality changes over the last year with episodes of abnormal, aggressive and impulsive behaviour.
On examination there are moderate cognitive deficits but no signs of movement or gait abnormalities.
Which of the following is the most likely diagnosis?
Frontotemporal dementia (Pick’s disease)
Impulsivity, relatively young age and lack of movement abnormalities point towards this diagnosis.
A 42 year old lady who has lived in a nursing home for many years due to severe learning difficulties is being assessed for a chronic decline in memory.
On examination she has a protruding tongue, prominent epicanthal folds and a single transverse palmar crease.
Cognitive testing shows profound decline in memory.
She has Down’s syndrome confirmed on karyotyping when she was an infant.
Pathological examination of her brain would show changes in keeping with which of the following conditions?
Alzheimer’s disease
Alzheimer’s disease is caused by an accumulation of amyoid plaques, and the tau protein is also implicated.
Down Syndrome is caused by Trisomy 21, and the amyloid precursor protein is found on chromosome 21.
The extra copy of APP leads to early onset beta-amyloid plaques.
A 55-year old woman presents with a 4-year history of a progressive difficulty in speaking.
Her friends have noticed that she struggles to remember their names and struggles to find the correct word for certain objects, often resorting to calling them ‘thingy’.
Physical examination is normal.
A neuropsychological profile identifies deficits only when performing tasks that involve naming or assigning meaning to objects.
What is the most likely diagnosis?
Semantic dementia
This patient presents with a very specific deficit in semantic memory (the ability to associate meaning to objects presented via visual or auditory modalities).
Her history is suggestive of semantic dementia, a form of frontotemporal dementia (FTD).
FTD tends to affect individuals at a younger age than Alzheimer’s disease. The peak ago of onset is 55-65 years.
What is Lanugo hair associated with?
This is fine downy hair growth all over the body in response to malnourishment and is associated with anorexia.
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? (2)
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.
The learning point here is that you should always check a patient’s ECG before starting anti-cholinesterase inhibitors.
Contra-indications include prolonged QT, second or third degree heart block in an unpaced patient and sinus bradycardia <50 bpm.
Along with Cognitive stimulation and of equal consideration are the “Bio-psycho-social” aspects of holistic management for a patient which may include a carer referral, information giving, support groups, psychoeducation, and Advance Care Planning.
A 75 year old man presents to his GP with a 12 month history of gradually increasing forgetfulness.
His wife accompanies him and reports that he has left the house without locking the door and left the gas on after cooking on a few occasions.
She has always noticed so she does not feel either of them are at risk, but she is concerned about his memory.
He has a history of depression but has not had a recurrence of low mood for several years.
He often cannot find the word he is looking for, but there has been no other impact on his daily functioning.
Neurological examination is normal.
What is the most appropriate pharmacological treatment?
What is the diagnosis?
Donepezil
This man’s history is highly suggestive of Alzheimer’s disease, a chronic and progressive form of dementia.
Acetylcholinesterase inhibitors such as Donepezil, Galantamine and Rivastigmine are recommended by NICE guidelines as options for managing mild to moderate Alzheimer’s disease.
Donepezil is not a cure for Alzheimer’s disease, but it can slow the progression of its course.
Name three anti-cholinesterase inhibitors
(3)
Donepezil
Galantamine
Rivastigmine
What is Memantine?
Which receptor does it affect?
Memantine is a NMDA receptor antagonist that is used for the treatment of severe Alzheimer’s disease.
It is also a therapeutic option for those with moderate disease who are intolerant to acetylcholinesterase inhibitors, or where they are contraindicated.
A 34 year old woman is brought into A&E by her husband.
He says that over the past 2 days she has begun to act strangely, including speaking to people that aren’t there.
She has become increasingly withdrawn and anxious.
Her elder brother was diagnosed with schizophrenia as a teenager and the husband is concerned that she might have it too.
The woman has no relevant past medical history and takes no medication.
Her most recent observations are stable and she is afebrile.
What is the first investigation for this patient?
Urinary toxicology
This is an appropriate first line investigation in this woman with a short history of psychotic symptoms.
Drug intoxication could easily cause a psychotic picture and is important to rule out.
A 27 year old woman is brought into A&E after a paracetamol overdose.
She says she had an argument with her boyfriend and took the overdose as she “can’t live without him”.
This is the third overdose she has taken in the past 18 months.
When you go to speak with the patient you notice scars on both forearms consistent with self-harm.
She says that you are “the best, kindest doctor she’s ever met” and that she previously had a row with one of the nurses who was “completely useless and needs to be fired”.
What personality disorder is this patient most likely to have?
Emotionally unstable
This patient is demonstrating the unstable relationships and self-injurous behaviour classically associated with BPD.
She also employs ‘splitting’- where individuals are considered wholly good or bad.
A 14-year-old female present to A&E with dizziness and palpitations. She is breathing very rapidly and looks anxious.
The patient is not confused and does not have tinnitus.
The following investigations are performed:
ABG:
- pH: 7.48 (7.35-7.45)
- PaO2: 15.4KPa (>10)
- PaCO2: 2.9KPa (4.7-6.0)
- HCO3: 22mmol/L (22-26)
- ECG: normal sinus rhythm
- D-dimer: 194 (<500)
- Troponin: 10 (<14ng/l)
- Repeat Troponin: 10 (<14ng/l)
What is the most likely diagnosis?
- Panic attack
- This patient has an acute respiratory alkalosis secondary to hyperventilation.
She appears anxious and has other features of a panic attack, including dizziness and palpitations.
Before making this diagnosis, it is important organic causes are excluded.
A 69 year old man comes in with complaints of progressive memory loss.
His family have noticed that this is gotten worse over the last two years.
In the last year he had occasionally forgotten to pay his rent but has been found lost in his village several times in the past 6 weeks.
He has a history of atrial fibrillation, hypertension, hypercholesterolemia and type II diabetes.
His only medication is atorvastatin and metformin.
This patient is most likely to have which type of dementia?
Vascular dementia
Classically described as a stepwise decline in function, it can be clear if one has had a known history of TIAs or strokes.
In this scenario it is likely he had a series of subclinical strokes with no focal neurological deficits which have slowly reduced his cognitive reserve.
With his risk factors and the lack of preventative treatment for his AF, his risk for further vascular insult is very high.
A 49 year old woman presents to her GP with a 9 month history of nervousness.
She feels generally tense and worried most of the time, experiencing palpitations, muscular tension, and fears of something bad happening to her on a daily basis.
She is able to continue with her usual daily routine.
Her symptoms have not improved, despite psychoeducation and Cognitive Behavioural Therapy.
What is the next most appropriate treatment?
Sertraline
This woman has Generalised Anxiety Disorder.
NICE guidelines suggest that treatment follows a stepped care approach, initially with active monitoring and psychoeducation, then with individual self-help (e.g. online workbooks).
If these do not work, a high-intensity psychological therapy such as Cognitive Behavioural Therapy should be offered, or pharmacological therapies.
The most appropriate first line drug treatment in Generalised Anxiety Disorders is Sertraline.
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?
Acute stress reaction
The short duration and strong dissociative symptoms this patient describes are characteristic of an acute stress reaction.
A 55-year old man is rushed into the Emergency Department.
He is complaining of severe abdominal pain, nausea, and drowsiness.
He is known to have bipolar disorder and reports recently starting bendroflumethiazide.
He has a fine tremor and ataxic gait on examination.
His lithium level is 1.6mmol/l (normal level <1.5mmol/l).
A diagnosis of lithium toxicity is suspected.
What is the most appropriate management in this scenario?
Fluid resuscitation
Bendroflumethiazide increases the serum concentration of lithium through its effects on renal sodium reabsorption and therefore it should be stopped.
The mild-moderate toxicity in this case may respond to volume resuscitation with normal saline.
Drug interactions predisposing to toxicity include medications such as NSAIDs, furosemide, thiazide diuretics, ACE inhibitors and some antidepressants.
Mild toxicity is characterised by nausea, diarrhoea, blurred vision, polyuria, dizziness, a fine resting tremor, muscle weakness or drowsiness.
Drug interactions predisposing to toxicity include medications;
(5)
Drug interactions predisposing to toxicity include medications;
NSAIDs
furosemide
thiazide diuretics
ACE inhibitors
tricyclic antidepressants
A 44 year old lady presents to the GP feeling tired all the time.
She is waking up early and struggles to get back to sleep.
She has a reduced appetite and has no energy to go to her weekly book club meetings.
She feels guilty about letting her friends down and becomes very tearful.
She explains she has been feeling like this for 2 years ever since her sister passed away.
What is the most likely cause of her symptoms?
Depression
This patient has a persistent history of the core features of depression; low mood, anhedonia and reduced energy, along with biological symptoms of depression including early morning wakening and reduced appetite.
Grief Reaction
Although her sister passing away is likely to have had a role to play in the development of this patient’s depression, grief reaction is a form of adjustment disorder that starts within 3 months of the stressor and does not persist for longer than 6 months. The duration of this lady’s symptoms suggests a depression rather than a grief reaction
A 26 year old woman comes into the GP surgery looking tearful. She says that she is struggling to cope and feels unable to eat and sleep. She reports feeling exceptionally low and often cries. Her past medical history is unremarkable.
You suspect a diagnosis of depression.
Which of the following blood tests is most appropriate initially in this patient?
Thyroid function test
This is the correct answer. Hypothyroidism is a well recognised cause of depression.
A 65 year old man with a history of hypertension, schizoaffective disorder and Parkinson’s disease is admitted to hospital with pneumonia.
On day six of admission, he becomes agitated towards the nurses and other patients, demanding to go home.
He is verbally aggressive and walking around the ward in a threatening manner.
Verbal de-escalation techniques are unsuccessful and he refuses to take medication orally.
His regular medications include Ramipril, Levodopa, and Atorvastatin.
Which of the following is the most appropriate drug to administer?
Intramuscular (IM) Lorazepam
This is the most appropriate option in an acutely distressed patient who poses a risk to themselves or others, after verbal de-escalation techniques have been trialled.
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.
A 32 year old accountant is brought into the A&E department by his girlfriend.
She describes him ‘behaving strangely’ for the past week.
He has stayed out all night partying and spending large amounts of money.
He has a past medical history of depression for which he takes citalopram 20mg OD.
You go to examine the patient and find him singing loudly in the cubicle.
He is unkempt but seems cheerful and friendly.
He exhibits flight of ideas and pressured speech.
What is the most appropriate acute management for this man?
Stop citalopram, start oral risperidone
An oral anti-psychotic is a good choice for this patient, as he is experiencing a moderate manic episode without agitation.
His citalopram also needs to be withheld during his manic episode as it will exacerbate the mood disturbance.
A 30 year old woman attends the GP to discuss her mood.
She tells you she has been feeling particularly low since her recent divorce and job loss.
She comments that life is worthless and she no longer sees the point of living.
She has stopped eating and drinking because she doesn’t want to ‘waste’ food and water on herself.
She has been self-harming.
On further questioning she reveals that she has sent out letters to all her loved ones as she is planning to ‘end it soon’.
You are worried about her safety and ask her consent to be reviewed in hospital by the psychiatry team, however she refuses, saying she ‘cannot wait any longer’.
You see from her notes that she has no past medical history and very little prior contact with the GP.
Which of the following sections of the Mental Health Act would be most appropriate to use in this situation?
Section 2
Different sections of the Mental Health Act are used in different situations.
All of them are to protect the safety of the patient and/or those around them.
A Section 2 is also known as an ‘assessment order’.
Patients can be admitted under this for up to 28 days with a view to assess and diagnose the underlying disorder.
It would be appropriate in this case where a patient is posing a risk to themselves; she is likely experiencing a severe depressive episode with psychotic features and needs further assessment in hospital.
A 28 year old woman is brought to A&E by ambulance after being found walking on the roof ledge of a multi-storey car park.
She said she was about to practise flying, and has a fixed belief that she is able to do this.
On examination she is moving around the room, finding it difficult to keep still, talking rapidly and seems elated.
Urine drug screen is negative and routine blood tests show no abnormalities.
On contacting her family, they report she had a severe depressive episode one year ago and her mother had similar symptoms.
What is the most likely aetiology of her condition?
Genetic inheritance
This lady fits diagnostic criteria for Bipolar Affective Disorder, presenting with a manic episode on the background of a severe depressive episode.
She presents with the mood-congruent delusion that she can fly, putting her at high risk of harm. Although it is not certain which genes are affected, Bipolar Affective Disorder does run in families and aetiology has a genetic component, especially with first-degree relatives.
A 45 year old woman presents to the GP with low mood, tiredness, and weight gain.
She tells you that for the past two months she feels tearful all the time and is gaining weight despite having reduced appetite.
She has a past medical history of coeliac disease.
Her regular medications include Ferrous Sulphate and Cerazette.
On examination, you note dry skin and thin hair.
Which of the following investigations is likely to diagnose this condition?
Thyroid function tests
It is important to be aware of the differential diagnoses of low mood.
Hypothyroidism is a recognised cause of low mood and can mimic depression.
It can also cause the physical symptoms this patient is experiencing: fatigue, weight gain, dry skin and hair, as well as constipation, oedema, and proximal myopathy.
This patient has a history of another autoimmune condition, which further points to an underlying physical cause of her depression.
