Day 5 PSYCH 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.
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.
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?
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.
A 17 year old girl comes to the GP surgery complaining of absent periods for the past 6 months.
She denies being sexually active and previously had a regular 28 day cycle since the age of 13.
On examination she is wearing multiple layers of clothing, and appears underweight and malnourished.
You notice a fine layer of hair covering her skin.
Which of the following blood results when you expect to find, given the most likely diagnosis?
Hypercholesterolaemia
Patients with anorexia nervosa exhibit hypercholesterolaemia.
The pathophysiology is unclear, however it is thought to be due to alterations in the metabolic pathway.
A 30 year old woman presents to the GP complaining of low mood for the past 3 months.
She thinks this is being exacerbated by her recent weight gain and hair loss.
Her colleagues have been unkind about her “puffy face”.
She also notes that her periods have been especially long and heavy lately.
On observation she seems tearful and is slumped down low in her large coat.
Which of the following investigations is most likely to identify the diagnosis?
Thyroid function test
This is the correct answer. This patient displays clear signs of hypothyroidism, which is causing her low mood.
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?
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.
A 23 year old woman with a 12 month history of Anorexia Nervosa is admitted to a specialist eating disorders unit, due to rapid recent weight loss and concerns about her very low calorie intake (less than 500 kcals per day). On admission she has routine blood tests taken and an ECG is performed which is abnormal.
Which of the following ECG findings are more common in patients with severe Anorexia Nervosa? (2)
Prolonged QT interval
- A prolonged QT interval (>450ms) is often seen in those with Anorexia Nervosa, secondary to weight loss or electrolyte disturbance.
- It is important to detect this, as it can predispose to potentially fatal arrhythmias.
An 18 year old woman presents to her GP with feelings of tiredness.
She describes a six month history of exercising every day, despite having very little energy, deliberately trying to lose weight because she believes she is fat.
She reports deliberately restricting her food intake to 500 - 800 calories per day because she does not want to gain any more weight.
She does not self-induce vomiting and denies use of any laxatives.
On examination she is markedly underweight, with lanugo hair.
What is the most likely finding on routine blood tests?
Low white cell count
This woman fits diagnostic criteria for Anorexia Nervosa.
She has been deliberately restricting her food intake over a prolonged period of time, and given that she is noticeably underweight, her blood results are likely to show a reduced white cell count secondary to malnutrition.
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.
Which is the first investigation that should be done?
Serum vitamin B12
Although this man’s history is highly suggestive of Alzheimer’s disease, a chronic and progressive form of dementia, it is important to rule out any reversible causes of cognitive decline, such as vitamin B12 deficiency.
Given the simplicity of a blood test, it is advisable to do this before considering other investigations such as brain imaging.
Susan is a 35-year-old woman who has been brought in to see you, in primary care, by her partner.
Three days ago, she delivered her first child. Since then, her partner reports that she has been violent towards her and Susan’s mother.
She claims that Susan believes the child isn’t hers and that she has been experiencing voices telling her to ‘deal with it’.
She reports that Susan has had minimal engagement with the baby and appears distraught when challenged as to why.
There is no medical history of note, however, Susan’s father and sister suffer from bipolar affective disorder.
Given the most likely diagnosis, which of the following is the most appropriate course of action?
Organise admission to a Mother and Baby Unit (MBU)
Susan seems to be experiencing auditory hallucinations instructing her to harm her child.
Further, her behaviour towards her mother and partner has changed and she has already been violent towards them.
This constitutes a significant risk of harm to others and likely indicates that Susan is at risk of coming to harm herself.
As such, she likely needs specialist treatment in an MBU and treatment with antipsychotics in order for her to recover from this episode and connect with her baby
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 likely histo-pathological finding?
Amyloid plaques
This man’s history is highly suggestive of Alzheimer’s disease, a chronic and progressive form of dementia.
Alzheimer’s disease is caused by a build up of amyloid protein deposits around brain cells and tau protein tangles within brain cells.
A 60 year old woman is brought to the GP by her daughter, who is worried about her mother’s memory. The daughter describes sudden deteriorations in her mother’s cognitive ability and memory followed by periods of relative stability.
You review the notes and see that her mother is a lifelong smoker of a packet a day, has a BMI of 35 and poorly controlled diabetes.
What is the most likely diagnosis?
Vascular dementia
This is correct. The step-wise deterioration is classically seen in vascular dementia, and this patient has numerous risk factors for vascular disease (smoking, obesity and diabetes).
A 29 year old lady presents with reduced libido, infertility, and galactorrhoea.
Physical examination is unremarkable, and a more detailed history indicates that one of her regular prescription drugs may have caused these symptoms.
Which of the following drug types is most likely to be responsible for this presentation?
Dopamine antagonists
Dopamine antagonists can act upon the posterior hypothalamus causing increased release of prolactin (leading to galactorrhoea) as well as interferring with other pituitary hormones.
An 85 year old woman is brought into the GP surgery by her son.
The son describes a one week history of change in mood, where the patient has become more withdrawn and finds it difficult to hold a conversation.
The son also confides that his mother has been incontinent of urine several times over the past few days and is complaining of stomach ache.
What is the most important initial investigation for this patient?
Urine culture
The history is highly suspicious of a delirium secondary to UTI.
Although urine dips can be readily performed at the bedside, they are unreliable in those >65.
Therefore urine culture would be most appropriate initial investigation.
Clearly it will take several days to obtain the results of the culture and empirical treatment should be commenced in the meantime.
A 52 year old man is brought into the GP surgery by his wife.
She says that she is at “the end of her tether” with her husband.
Over the past few months he has started to act extremely out of character, going gambling most evenings and eating huge amounts of sweet food.
His memory has deteriorated and he often loses his wallet and keys.
The man passes away shortly after your consultation of unrelated causes.
He dies.
What does histo-pathology show?
What is the diagnosis?
Pick’s disease
This patient displays the classical symptoms of early fronto-temporal dementia; including dis-inhibition and personality change with other functions relatively preserved.
The pathology findings (intra-cellular TAU proteins and atrophy of the frontal and temporal lobes) are consistent with a diagnosis of Pick’s disease.
The pathologists report collections of intracellular TAU proteins and atrophy of the frontal and temporal lobes.
A 25 year old medical student is diagnosed with schizophrenia after being admitted in a psychotic episode.
Which features in the history is linked to a good prognosis for this patient? (5)
- High IQ/education level
- Sudden onset
- Obvious precipitating factor such as a traumatic life event
- A strong support network
- Positive symptoms predominant
A 32 year old woman comes to the GP surgery complaining of generalized pain and fatigue.
This has been ongoing for almost a year and you see that despite numerous investigations ordered by your colleagues, no abnormality has been found.
The patient tells you that this pain is stopping her from looking after her children, and her mother is now providing the majority of the childcare.
What is the most appropriate management for this patient?
Explain that you think there is unlikely to be an organic cause to this problem, but offer psycho-social support
This is correct. MUS are a common problem in primary care. A sensitive consultation style that allows the patient the opportunity to talk about their experiences and worries is beneficial. Psycho-social support and therapies such as CBT are helpful in reducing symptoms.
A 25 year old student presents to the GP complaining of palpitations.
He describes them as his heart suddenly beating very fast and sometimes it feels like it skips a beat.
When this happens he also feels dizzy, as though he may faint, but never has. They have occurred on occasion during exercise.
He tells you they are very worrying and he feels ‘on edge all the time’.
He has no past medical history and there is no relevant family history.
He smokes 5 cigarettes a day, occasionally uses marijuana and admits to drinking in excess on weekends because of ‘student life’.
On examination, his observations and a cardiovascular examination are normal.
Which of the following is the most important next step management?
Refer for 48-hour holter monitor ECG
Generally, all patients who present with new onset of palpitations with no clear cause should be referred for further investigation.
The first line investigation is a 24 or 48 hour holter monitor ECG.
NICE recommend especially that those with certain features are investigated - exercise-induced palpitations and a history of syncope or near-syncope are two of these.
This patient should be referred to investigate for a hereditary or structural cause of arrhythmia.
An 82 year old lady with a past medical history of stroke and irritable bowel syndrome attends your GP Surgery with her daughter.
Her daughter is concerned that her mother’s memory has deteriorated over the past 12 months.
She is often found wandering the village looking for her husband who passed away 4 years ago and cannot recall her current address.
She lives on her own and sometimes forgets to turn the hob off after she has been cooking.
She is otherwise well with no other symptoms.
Past medical history includes a TIA 10 years ago.
She is on an atorvastatin 20mg and amlodipine 5mg.
Clinical examination, including neurological examination is unremarkable. She is afebrile with normal observations.
A urine dipstick test shows no abnormality.
You conduct an Abbreviated Mental test Score and the patient scores 6 / 10.
Which is the most likely diagnosis for this patient?
Vascular Dementia
This lady has had a decline in her memory over a relatively long period of time, particularly affecting short term recall of things such as address and simple tasks around the home. Dementia is a progressive disease consisting of cognitive impairment (as demonstrated by an AMTS <8) which can affect behaviour, mood and the ability to carry out activities of daily living. The history of a TIA could point towards a specific diagnosis of vascular dementia. The next steps in management would be to rule out reversible causes of the cognitive function (blood tests including B12 and folate and thyroid function and a urine dip) and a referral to memory clinic.
A 30 year old man with schizophrenia attends the outpatient psychiatry clinic for review.
There has been no improvement on his current medication, Aripiprazole.
He has used Haloperidol in the past, which also did not help.
Which of the following is the most appropriate drug to prescribe next?
Clozapine
Schizophrenia that does not respond to two consecutive trials of antipsychotics is defined as treatment-resistant schizophrenia. Clozapine is an antipsychotic medication reserved for these cases. It has many monitoring requirements and is a frequent topic tested in exams.
A 23 year old male presents to A&E complaining of blood in his urine.
He has brought a urine sample with him that tests positive for traces of blood on urinalysis.
He also complains of generalised abdominal pain and is rolling around on the examination couch.
A renal stone is suspected.
However, all investigations are negative. He is sent to the ward.
Later on, the nurses tell you that they suspect the patient has been tampering with the urine samples, as they noticed his arm was bleeding after going to produce a sample.
You review the patient’s notes and see that this is the fifth admission in the past year for similar symptoms.
What is the likely diagnosis of this patient?
Munchausen’s syndrome
The patient in this question is intentionally faking signs and symptoms (i.e. adding blood to urine and complaining of pain) in order to gain attention and play “the patient role”.
This is consistent with Munchausen’s syndrome.
A 39 year old man presents to A&E saying that he feels unwell.
He appears drowsy and confused.
On further questioning, he admits to having taken a substance but will not disclose which substance.
On examination his vital observations are:
- pulse 40bpm
- respiratory rate 10/min
- temperature 37.0 degrees
- BP 126/84
- O2 sats 98% on room air
He has constricted pupils and there is evidence of needle marks in his left antecubital fossa. Following acute management, which of the following treatments is most appropriate to treat this patient’s drug dependence?
Selective serotonin reuptake inhibitor
This woman presents with symptoms of a moderate depressive episode, with biological symptoms of depression, without psychotic symptoms.
If pharmacological therapy is to be offered (after consideration of psychological therapies, either before medication or in conjunction with it), a selective serotonin reuptake inhibitor should be offered.
An example of this is Sertraline, which acts by preventing the reuptake of serotonin at the synaptic cleft.
A 58 year old male presents to clinic with his daughter.
She says that her father has started to lose his memory and has been acting strange.
Also, he has become incontinent of urine as of late and upon examination, he has a shuffling gait with a stooped posture.
What management should be commenced in this patient?
What is the diagnosis?
Ventriculoperitoneal shunting
This is Normal Pressure Hydrocephalus; Wet, Wobbly and Wacky otherwise presenting as urinary incontinence, gait dysfunction and dementia.
In reality, the first line investigation/treatment would be a lumbar puncture and if relieving the pressure resolves the symptoms a ventriculoperitoneal shunt would be inserted.
A 64-year-old man is admitted from his care home after suffering from recurrent falls.
His most recent fall was unwitnessed and may have hit his head.
His carers report that he hasn’t quite been himself in the past twelve months.
He has been more difficult to manage as he often wets himself and now has difficulty mobilising.
He has not had any headaches, nausea nor vomiting.
What is the diagnosis?
Which of the following is the most likely investigation finding?
Enlarged ventricles and absent sulci seen on CT brain scan
This man is is presenting with the triad of “Wet, Wobbly & Weird”. This is typical of Normal Pressure Hydrocephalus, which is caused by an abnormal increase in cerebrospinal fluid (CSF) in the ventricles. The sulci are absent because they are compressed by the ventricles which allows for the pressure to be normal despite the CSF increase. The fact that he has not had headaches, nausea nor vomiting helps to point away from any causes of raised intracranial pressure.
